Phẫu Thuật Da Liễu: Khía Cạnh Ngoại Khoa (Surgery of the Skin)

133
Chapter 8  Wound Healing and its Impact on Dressings and Postoperative Care
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9. Field CK, Kerstein MD. Overview of wound healing in a moist environ-
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11. Falanga V, Shen J. Growth factors, signal transduction and cellular
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17. Harris IR, Yee KC, Walters CE, et al. Cytokine and protease levels in
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18. Bucalo B, Eaglestein WH, Falanga V. Inhibition of cell proliferation by
chronic wound fluid. Wound Repair Regen 1993;1:181–186.
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23. Bello YM, Phillips TJ. The practical aspects of dressing therapy. Dermatol
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965–987.
25. Lopez AP, Phillips TJ. Wound healing. In: Fitzpatrick RE, Goldman MP,
eds. Cosmetic laser surgery. St Louis: Mosby; 2000.
26. Piacquadio D, Nelson DB. Alginates: a ‘new’ dressing alternative. J Der-
matol Surg Oncol 1992;18:990–998.
27. Choucair M, Phillips TJ. A review of wound healing and dressing materi-
als. Wounds 1996;8:165–172.
28. Valencia IC, Falabella AF, Eaglestein WH. Skin grafting. Dermatol Clin
2000;18:521–532.
29. Eaglestein WH, Falanga V. Tissue engineering and the development of
Apligraf, a human skin equivalent. Cutis 1998;62S:1–8.
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grafting. J Am Acad Dermatolol 1992;27:151–165.
31. Bello YM, Phillips TJ. Recent advances in wound healing. JAMA
2000;283:716–718.
32. Rheinwald JG, Green H. Serial cultivation of strains of human epidermal
keratinocytes: the formation of keratinizing colonies from single cells.
Cell 1975;6:331–334.
33. Ongenae KC, Phillips TJ. Cultured epidermal grafts. In: Robinson JK,
Arndt KA, LeBoit PE, et al, eds. Atlas of cutaneous surgery. Philadelphia:
WB Saunders; 1996.
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with cultured epithelium prepared from autologous epidermal cells.
Lancet 1981;1:75–78.
35. Bello YM, Falabella AF. Use of skin substitutes in dermatology. Dermatol
Clin 2001;19:555–561.
36. May SR, DeClement FA. Skin banking: Part I. Procurement of trans-
plantable cadaveric allograft skin for burn wound coverage. J Burn Care
Rehabil 1981;2:7–23.
37. May SR, DeClement FA. Skin banking: Part II. Low contamination of
cadaveric dermal allograft for temporary burn-wound coverage. J Burn
Care Rehabil 1981;2:64–76.
38. May SR, DeClement FA. Skin banking: Part III. Cadaveric allograft skin
viability. J Burn Care Rehabil 1981;2:128–141.
39. Hefton JM, Amberson JB, Biozes DG, et al. Loss of HLA-DR expression
of human epidermal cells after growth in culture. J Invest Dermatol
1984;83:48–50.
40. Leigh IM, Purkis P, Navsaria H, et al. Treatment of chronic venous ulcers
with sheets of cultured allogeneic keratinocytes. Br J Dermatol 1987;117:
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85. Collawn SS. Occlusion following laser resurfacing promotes reepitheliali-
zation and wound healing. Plast Reconstr Surg 2000;105:2180–2189.
86. Newman PJ, Koch J, Goode R. Closed dressings after laser skin resurfac-
ing. Arch Otorhinolaryngol 1998;124:751–757.
87. Phillips TJ. Current approaches to venous ulcers and compression. Der-
matol Surg 2001;27:611–621.
88. Rojas AI, Phillips TJ. Venous ulcers and their management. In: Falanga
V, ed. Cutaneous wound healing. London: Martin Dunitz; 2001.
89. Schmeller W, Gaber Y, Gehl HB. Shave therapy is a simple, effective
treatment for persistent venous ulcers. J Am Acad Dermatol 1998:39:
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90. Phillips TJ. Successful methods of treating leg ulcers. Postgrad Med
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91. Steed DL. Foundations of good ulcer care. Am J Surg 1998;176:
20S–25S.
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93. Fisken RA, Digby M. Which dressing for diabetic foot ulcers? J Br Pod
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94. Lipken S, Chaikof E, Isseroff Z, et al. Effectiveness of bilayered cellular
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95. Bergstrom, N, Bennett MA, Carlson CE, et al. Treatment of pressure
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96. Wooten MK. Long-term care in geriatrics. Clin Fam Pract 2001;
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97. Belmin J, Meaume S, Rabus MT, et al. Sequential treatment with calcium
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98. Ovington LG. Wound dressings: their evolution and use. In: Falanga V,
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Martin Dunitz; 2001.
71. Arpey CJ, Whitaker DC. Postsurgical wound management. Dermatol
Clin 2001;19:787–797.
72. Petkewich R. Liquid bandages. Chem Eng News 2008;86:61.
73. Robins P, Goldberg L, Moy R, et al. The effectiveness of liquid bandage
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75. Martin-Garcia RF, Janer AL, Rullan FV. Octyl-2-cyanoacrylate liquid
bandage as a wound dressing in facial excisional surgery: results of an
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76. Davis SC, Eaglstein WH, Cazzaniga AL, et al. An octyle-2-cyanoacrylate
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365–367.

PART 2
Essential Surgical
Skills

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137
9
Electrosurgery, Electrocoagulation,
Electrofulguration, Electrodesiccation,
Electrosection, Electrocautery
Seaver L Soon MD and Carl V Washington Jr MD
Summary box
 Electrosurgery refers to thermal tissue damage resulting
from tissue resistance to the passage of high-frequency,
alternating electric current. It includes electrocoagulation,
electrofulguration, electrodesiccation, and electrosection.
Electrocautery is not a true form of electrosurgery as no
current flows through the patient.
 The precise tissue effect of electric current – whether
superficial tissue dehydration, deep coagulation, or
pure cutting – depends on current density, voltage, and
electromagnetic waveform.
 Electrosurgery may be indicated for a variety of benign, and
superficially invasive, malignant neoplasms.
 Electrodesiccation and curettage generally provides high
cure rates for superficial and nodular basal cell carcinoma,
although these rates vary based on lesion size, histologic
subtype, and anatomic location.
 Randomized controlled studies suggest that modern
electrosection units provide superior speed, hemostasis,
cosmetic outcome, and less postoperative pain compared to
conventional scalpel surgery, with comparable postoperative
wound healing and infection rates.
 Electrocoagulation with biterminal forceps provides precision
as well as superior safety in relation to devices susceptible
to electromagnetic interference, such as implantable cardiac
pacemakers, defibrillators, and deep-brain stimulators.
 Electrochemotherapy refers to the use of electric pulses to
increase tumor uptake of chemotherapeutic agents, and may
be particularly useful in recurrent or inoperable cutaneous
malignancy or metastases.
 Adverse events associated with electrosurgery include
electrical burns, electric shock, infection transmission, eye
injury, and cardiac pacemaker and implantable cardioverter–
defibrillator malfunction. The actual risk of pacemaker and
implantable cardioverter–defibrillator malfunction is extremely
low, particularly with electrosurgery with biterminal forceps.
 INTRODUCTION
Electrosurgery refers to the use of electricity to cause thermal
tissue destruction, most commonly in the form of tissue
dehydration, coagulation, or vaporization. Electrosurgical pro-
cedures may be divided into four types based on their mech-
anism of tissue damage:
1. Electrolysis: uses direct current to induce tissue damage
via a chemical reaction at the electrode tip.
2. Coblation: uses high-frequency alternating current to
ionize an electrically conductive medium (usually
isotonic saline solution) and transmits heat to cause
superficial epidermal and dermal damage with minimal
collateral tissue destruction. Coblation is used for facial
rejuvenation.
3. High-frequency electrosurgery: uses tissue resistance to
the passage of high-frequency alternating current to
convert electric energy to heat, resulting in thermal
tissue damage. Heat generation occurs within the tissue,
while the treatment electrode remains ‘cold.’ This
method includes electrodesiccation, electrofulguration,
electrocoagulation, and electrosection.
4. Electrocautery: uses direct or high-frequency alternating
current to heat an element that causes thermal injury by
direct heat transference to tissue. In contrast with the
cold electrode of electrosurgery, the element in
electrocautery is hot.
This chapter addresses high-frequency electrosurgery and
electrocautery. Coblation is addressed in another section in
this text. Readers interested in electrolysis are referred else-
where.1 Dermatologic surgeons using these techniques should
be familiar with fundamental concepts in the physics of elec-
tricity – such as current, resistance, voltage, power, and elec-
trosurgical waveform output – as well as their effects on
the skin. Knowledge in this area may optimize preoperative
plans, choice of therapy, and postoperative results as well as
minimizing the risk of electrical injury to both patient and
physician.
Principles of electricity
Current, resistance, voltage, power, and electrosurgical wave-
form output are of clinical relevance as they determine the
quality and extent of tissue damage. Electrical current refers
to the net flow of electrons through a conductor per second,
and is measured in amperes (1 ampere = 6.242 × 1018 elec-
trons per second). An important concept regarding electric-
ity in medicine is that the amount of current is the same for
all cross-sections of a given conductor. This quantity refers
to current density, defined as the amount of current per
cross-sectional area (mathematically, j = i/A, where j is
current density, i is current, and A is the cross-sectional

138
Part 2  Essential Surgical Skills
neuromuscular activity ceases. If the molecular reorientation
induced by the direct current persists beyond this refractory
period, cell death occurs. Therapeutic uses of direct current
include electrolysis, iontophoresis, and, sometimes, electro-
cautery. To maintain cell viability, direct current may be
applied in intermittent pulses to allow for cell membrane
repolarization.2,4
Unlike direct current, alternating current continuously
switches direction. It is produced in power generators and is
available at electrical outlets. In North America, the average
electrical outlet carries an alternating current with a fre-
quency of 60 hertz (Hz; 1 Hz = 1 cycle per second). When
this type of current is applied to tissue, cellular ions are
alternately pulled to and fro, resulting in rapid cellular depo-
larization and then repolarization as the current changes
direction. Because cell membranes are rapidly depolarized
and then repolarized, alternating current causes tetanic neu-
romuscular contraction with frequencies <1 kilohertz (kHz).
This adverse effect decreases as frequency increases above
1 kHz, and becomes negligible at frequencies ≥100 kHz. At
area of the conductor). Thus, the thinner the electrosurgi-
cal tip (i.e. decreasing the cross-sectional area of the con­
ductor, A), the greater the current density, j, at the point
of electrode contact. High current density results in
greater tissue injury, and is the basis of surgical diathermy
(Fig. 9.1). Similarly, increasing the cross-sectional area of
the electrode by a sufficient amount may decrease current
density to a level where only non-destructive tissue warming
occurs. This warming effect is the basis of medical diathermy
(Fig. 9.2).2,3
The body acts as a conductor for electrical current due to
the electrolyte composition of its cells. In living tissue, current
flow consists of the transfer of charged ions within cells.
There are two main types of current: direct current and
alternating current. Direct current refers to electron flow in
one direction, and is usually produced by a battery. When
applied to living tissue, direct current depolarizes cell mem-
branes and leads to neuromuscular excitation. Should this
current be sustained for a period of time sufficient to prevent
cell repolarization, the cells enter a refractory period wherein
Treatment electrode
Indifferent electrode
Surgical diathermy
Figure 9.1  Decreasing the
surface area of the treatment
electrode increases current
density.
Treatment electrode
Indifferent electrode
Medical diathermy
Figure 9.2  Increasing the
surface area of the treatment
electrode decreases current
density.

139
Chapter 9  Electrosurgery, Electrocoagulation, Electrofulguration, Electrodesiccation, Electrosection
operate using between 15 and 150 watts of power, which
confers enough heat energy to vaporize water.2,6
‘Ohmic heating,’ or heat production as a result of tissue
resistance to electric current, depends on such factors as
resistance (and hence the resistivity and the length of the
conductor), current density, and the duration of current
application. For a given current density, heat production is
greater in fat than muscle because of its higher resistivity. As
resistance is proportional to conductor length, increasing the
distance between a treatment and an indifferent electrode on
the body similarly yields greater heat. Minimal heat is gener-
ated in substances of little resistance; a clinical example is the
inefficacy of electrosurgery in the presence of blood, an elec-
trolyte conductor. Increasing the current density or the dura-
tion of current application also results in greater thermal
injury.2,4
As mentioned, standard electrical outlets in North America
provide an alternating current of 60 Hz and 110 V. Electro-
surgical procedures, however, require much higher frequen-
cies (as low frequencies induce tetany); a range of voltage and
current intensities; as well as different waveforms to provide
the appropriate level of destruction for the clinical indication.
These ends are achieved through current modification by the
electrosurgical unit.
Electrosurgical units and waveforms
An electrosurgical unit is essentially a high-frequency current
generator consisting of three components: (1) a transformer
that modifies the voltage, (2) an oscillating circuit that
increases the frequency, and (3) the patient circuit that is
comprised of the handpiece, the patient, and, in certain cases,
the indifferent electrode. A transformer is a device that uses
alternating current in one circuit to produce a voltage and
current in a second circuit, and consists of two wire coils
placed adjacent to one another. Available current from the
electrical outlet flowing through the first or primary coil
induces current flow in the secondary coil as a result of elec-
tromagnetic induction. The voltage of the induced current is
directly proportional to the number of windings in the sec-
ondary coil relative to the primary coil. For example, if the
number of windings in the secondary coil is 10 times that of
the primary coil, then the voltage of induced current is
increased 10-fold. This type of transformer is termed a ‘step-
up’ transformer to reflect this voltage amplification. The
voltage of the induced current may be similarly decreased
should the secondary coil have fewer windings than the
primary coil. This type of transformer is termed a ‘step-down’
transformer. Whereas a ‘step-up’ transformer is used in the
spark-gap electrosurgical unit, and typically increases the
available electrical voltage from 120 V to 550–>2000 V, both
‘step-up’ and ‘step-down’ transformers are used in the vac-
uum-tube electrosurgical unit (Fig. 9.3).7
Following voltage transformation, current from the second-
ary coil enters an oscillating circuit, which increases the fre-
quency from the available 60 Hz to >200 kHz. Two types of
oscillatory circuits exist based on the component that pro-
duces the oscillation: the spark-gap unit and the vacuum-tube
unit. Both consist of a condensor (or a capacitator, which
stores electric charge), a coil of wire (termed a solenoid), and
a small air gap – a spark gap in the case of the spark-gap type,
or a thermionic tube in the case of the vacuum-tube unit. The
air gap in the spark-gap apparatus resists electric current,
these high frequencies, current reversal is so rapid that cel-
lular ion position change is essentially nil, and depolariza-
tion fails to occur. Instead, electrical energy is converted to
heat as a result of ionic collision. High-frequency alternating
current thus makes it possible to exploit the heating effects
of electricity while avoiding the undesirable neuromuscular
effects. Electrosurgical units for electrosurgery and electro-
cautery utilize frequencies of 500– 2000 kHz.4,5
Important concepts related to current include resistance
and voltage. Resistance refers to the ability of a conductor to
impede the passage of an electric current, and is measured in
ohms (Ω). The resistance of a substance correlates with its
length and cross-sectional area, as well as its resistivity (math-
ematically, R = ρ × l/A, where R is resistance, ρ is resistivity,
l is length, and A is cross-sectional area). Resistance is pro-
portional to the length of the substance, and inversely pro-
portional to its cross-sectional area. A material’s resistivity
refers to its inherent capacity to resist electric current. The
human body is not a homogeneous electrical conducting
medium, but consists of different tissues of varying resistiv-
ity. Fat has high resistivity, whereas muscle has low resistiv-
ity. Skin has variable resistivity depending on whether it is
wet or dry: the resistivity of dry skin is colossal at 100 000 Ω,
whereas that of wet skin is much lower at 200 Ω.
Voltage refers to the electrical force that induces electron
flow when it is applied to a conductor, and is measured in
volts (V). This so-called ‘electromotive’ force is generated by
an electrical potential difference between the two ends of the
conductor: one end is considered the negative pole (having a
high concentration of negatively-charged electrons), while
the other is considered the positive pole (having a low con-
centration of negatively-charged electrons). Electric current
always flows from a region of high electron concentration to
one of low electron concentration. Ohm’s law captures the
relationship between voltage, current, and resistance math-
ematically as V = iR (where V is voltage, i is current, and R
is resistance). Thus for a given resistance, R, increasing the
voltage increases current flow through a conductor, whereas
decreasing the voltage decreases this flow. The average voltage
available at electrical outlets is 110 V.6
The concept of power encompasses how current, voltage,
and resistance interact to produce heat in tissue. Power (P)
is defined as the rate at which work is done (P = W/t, where
W is work, and t is time) and is measured in watts (joules/
second). This equation states that a given amount of work
can be done in less time with increasing power. Work (W) is
defined as the product of force by the distance over which
the force is applied (W = F × d, where F is force and d is
distance), and is measured in joules. In electricity, the work
done refers to current flow over a specific distance as a result
of a voltage difference. Tissue resistance to the passage of this
current results in heat production. Power thus refers to the
rate of heat energy produced as a result of tissue resistance
to the passage of current induced by a voltage potential.
Mathematically, P = iV (where P is power, i is current, and
V is voltage). By substituting Ohm’s law (V = iR, or i = V/R),
it is apparent that P = i2R, or P = V2/R. That is, power or
heat produced is proportional to the product of the square
of the current and tissue resistance, or the square of the
voltage divided by tissue resistance. Thus power will increase
with increments in both current and voltage; however, as
resistance is constant, power increases more significantly with
an increase in current than voltage. Most electrosurgical units

140
Part 2  Essential Surgical Skills
Spark
Gaps
Condensers
d'Arsonval coil
Main transformer
'STEP UP'
TRANSFORMERS
'STEP UP'
'STEP DOWN'
Rectifier
AC DC
HIGH
VOLTAGE
CIRCUIT
Voltage
markedly
increased
OSCILLATORY
CIRCUIT
Frequency
greatly
increased
Inductance
PATIENT
CIRCUIT
HIGH VOLTAGE
AC
HIGH FREQUENCY
LOW VOLTAGE
AC
LOW FREQUENCY
Oudin coil
Biterminal
Volts ++
mAmps ++
Biterminal
Volts +
mAmps ++++
Monoterminal
Volts ++++
mAmps +
60 Cycle
110 Volts
POWER SUPPLY
Coagulation
Desiccation
Cutting
Cutting
Cutting
Damped ++++
Damped +
Undamped
Modulated
interrupted
varying voltage
Coagulation
SPARK GAP
GENERATOR
VALVE TUBE
WAVEFORM
AND
EFFECT
Spark-gap units produce damped waveforms
Figure 9.3  Spark-gap units produce damped waveforms. Vacuum-tube units produce undamped as well as blended waveforms.
(Adapted from Crumay HM. Electrosurgery, cryosurgery, and hyperbaric oxygen therapy. In: Moschella SL, Hurley HJ. Dermatology.
Philadelphia: WB Saunders; 1985.)

141
Chapter 9  Electrosurgery, Electrocoagulation, Electrofulguration, Electrodesiccation, Electrosection
amplitudes to gradually decrease to zero. Vacuum-tube units,
by contrast, produce undamped waveforms because the ther-
mionic tube neutralizes the internal resistance within the
circuit, and allows the waveform to continue unchanged (see
Fig. 9.3). Changing the characteristics of the oscillating unit,
however, modifies the output waveforms in both units. In the
spark-gap unit, widening the spark gap requires a greater
voltage to jump the gap and produces highly damped waves
with the potential for great tissue destruction and hemostasis.
Narrowing the spark gap decreases the voltage necessary to
jump the gap, and causes the wavetrains to be less damp and
to occur closer together. Because this waveform more closely
resembles a sine wave, it has less potential for tissue damage
and hemostasis. Spark-gap units may thus be used for damped,
as well as relatively undamped, output.
A vacuum-tube unit may produce waveforms that are par-
tially rectified, fully rectified, or filtered and fully rectified,
depending on the components in its oscillating unit. Partial
rectification yields moderately damped waveforms, whereas
full rectification yields slightly damped waveforms. Full, fil-
tered rectification yields a completely undamped sine wave.
Markedly damped waveforms are used in electrofulguration
and electrodesiccation; moderately damped waveforms in
electrocoagulation; and undamped waveforms in electrosec-
tion (Table 9.1). Similar to spark-gap units, then, vacuum-
tube units may produce a spectrum of waveforms, from
moderately damped to purely undamped, depending on the
components of their oscillating unit. As they profoundly influ-
ence the quality and extent of tissue injury, intelligent use of
such electrical concepts as current density, resistance, voltage,
power, and waveform output may optimize therapy and min-
imize adverse events during electrosurgery.4,7,9
 PREOPERATIVE PREPARATION
Preoperative care should attempt to minimize risks specific
to electrosurgery. History and physical examination should
characterize risk factors for excessive blood loss, such as
bleeding diathesis, or poor healing, such as vasculopathy, mal-
nutrition, diabetes, or poor general medical condition. Patients
with cardiac pacemakers, deep-brain stimulators, or implant-
able cardiodefibrillators must also be identified as these
devices may malfunction in the presence of electromagnetic
radiation. Patients should remove all jewelry, and avoid
contact with grounded metal objects to minimize the risk of
electric burns. A non-alcohol-containing solution such as
chlorhexidine or povidone-iodine should be used, as alcohol
may ignite when exposed to spark or heat. In the perianal
region, moist packing should be placed over the anus to
prevent ignition of methane.8,11,12
 TECHNIQUES AND
PRACTICAL APPLICATIONS
Before considering various types of electrosurgical proce-
dures, clarification of four, often misused, terms is necessary.
These terms are ‘monopolar,’ ‘bipolar,’ ‘monoterminal,’ and
‘biterminal.’
Monopolar versus bipolar
In electrosurgery, alternating current variably enters and exits
the tissue through the treatment electrode. As a result, the
whereas that in the vacuum-tube type may include a rectifier
that decreases or even neutralizes this resistance. A third type
of oscillating circuit, the solid-state transistor, produces
waveforms similar to vacuum-tube units, but allows for
smaller, more reliable units by using transistors to control the
current.7,8
The output waveform determines the precise effect of
current on tissue. High-frequency, alternating current
generates electromagnetic fields consistent with medium-
frequency, sinusoidal radio waves. The term ‘waveform’
refers to the shape of these waves, specifically whether they
are undamped or damped, and continuous or discontinuous
(Fig. 9.4). An undamped wave refers to a pure sine wave of
electromagnetic energy that causes pure tissue separation
with minimal hemostasis. As the wave dampens, oscillations
exhibit amplitude surges that progressively decrease, result-
ing in marked tissue destructive effects. Greater damping
leads to increased tissue damage and hemostasis, whereas
lesser damping leads to less hemostasis but better healing.
Uninterrupted waveforms are continuous, whereas inter-
rupted waveforms are discontinuous. Continuous wavetrains
result in greater tissue heating since the current flows for a
longer period of time.2,9
Spark-gap units produce damped waveforms because the
resistance offered by the spark gap causes successive wave
Continuous, undamped
Discontinuous, undamped
Continuous, damped
Discontinuous, damped
Tissue effect
Pure cutting
Pure cutting
Cutting and
coagulation
Desiccation and
coagulation
Types of waveforms
Figure 9.4  Specific waveforms yield specific tissue effects.
(Adapted from Sebben JE. Electrosurgery principles: cutting
current and cutaneous surgery – part 1. J Dermatol Surg Oncol
1988;14:29–31.)

142
Part 2  Essential Surgical Skills
Table 9.1  Types of electrosurgical procedures
TYPE OF
PROCEDURE
CIRCUIT
TISSUE
CONTACT
WITH ACTIVE
ELECTRODE
VOLTAGE
AMPERAGE
AIR-GAP
OUTPUT
TUBE
OUTPUT
HISTOLOGY
Electrofulguration
Monoterminal
No
High
Low
Markedly
damped
–
Tissue desiccation:
cell outlines
preserved, but
shrunken. Nuclei
elongated. Some
vessel thrombosis
Electrodesiccation
Monoterminal
Yes
High
Low
Markedly
damped
–
Tissue desiccation:
cell outlines
preserved, but
shrunken. Nuclei
elongated. Some
vessel thrombosis
Electrocoagulation
Biterminal
Yes
Low
High
Moderately
damped
Partially
rectified
Tissue coagulation:
Cell outlines lost
from massive
protein denaturation,
homogeneous
hyalinized
appearance. Vessel
thrombosis
Electrosection with
coagulation
Biterminal
Yes
Low
High
Slightly
damped
Fully
rectified
Cell disintegration
forming approximately
0.1 mm incision;
adjacent cellular
outline elongation
and mild coagulation
effect
Electrosection
Biterminal
Yes
Low
High
Undamped
Filtered,
fully
rectified
Cell disintegration
forming approximately
0.1 mm incision;
minimal coagulation
effect
Electrocautery
None (hot
wire)
Yes
Low
High
N/A
N/A
Amorphous tissue
with charred foci and
formation of steam
spaces
Adapted from Bennett R. Electrosurgery. In: Bennett R, ed. Fundamentals of cutaneous surgery. St Louis: CV Mosby; 1988,2 Boughton R, Spencer S. Electrosurgical funda-
mentals. J Am Acad Dermatol 1987;16:862–867,3 and El-Gamal H, Dufrersne R, Saddler K. Electrosurgery, pacemakers, and ICDs: a survey of precautions and complications
experienced by cutaneous surgeons. Dermatol Surg 2001;27:385–390.10
treatment electrode is not a true positive or negative pole.
Use of the terms ‘monopolar’ and ‘bipolar’ to describe any
procedure using alternating current is therefore incorrect.
Only electrosurgery based on direct current, such as elec-
trolysis, is truly polar in that the treatment electrode
functions as a negative pole that transmits unidirectional
current. The terms ‘monoterminal’ and ‘biterminal’ are
technically more correct when referring to electrosurgical
procedures.13
Monoterminal versus biterminal
The prefixes ‘mono-’ and ‘bi-’ refer to the number of treat-
ment electrodes used in electrosurgery. ‘Monoterminal’ indi-
cates that only one electrode delivers current to the patient,
whereas ‘biterminal’ indicates that two electrodes are used
for this purpose. The second electrode is often a dispersive
electrode, serving to complete an electrical circuit that begins
in the electrosurgical unit, flows through the patient, and then
returns to the unit. Procedures not using an indifferent elec-
trode, such as electrodesiccation and electrofulguration, are
monoterminal, whereas procedures employing an indifferent
electrode, such as electrocoagulation or electrosection, are
biterminal. In monoterminal procedures, electrons are dis-
persed randomly to the environment.2
Electrosurgical procedures
Electrosurgical procedures may be classified based on the
degree of tissue destruction:
• Superficial: electrodesiccation and electrofulguration
• Deep: electrocoagulation
• Tissue cutting: electrosection
Types of electrosurgical procedures are summarized in
Table 9.1.

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Chapter 9  Electrosurgery, Electrocoagulation, Electrofulguration, Electrodesiccation, Electrosection
Electrofulguration and electrodesiccation
Electrofulguration and electrodesiccation use markedly damped,
high-voltage, low-amperage current in a monoterminal fashion
to produce superficial tissue destruction. The absence of an
indifferent electrode implies that current accumulates within
the patient; as a result, high voltage is required to sustain
current flow. Low amperage allows for nominal tissue damage.
In electrodesiccation, the electrode contacts the skin and
superficial skin dehydration occurs as a result of ohmic heating
(Fig. 9.5). Most damage is epidermal and there is minimal risk
of scarring with lower power settings. Higher power settings,
however, may be associated with increasing dermal coagula-
tion, superficial scarring, and hypopigmentation.
Electrofulguration represents a variation of electrodesicca-
tion in which the electrode is held 1–2 mm from the skin
surface, and causes superficial tissue dehydration by sparks
(Fig. 9.6). High voltage allows the current to overcome the
resistance of the air gap between the tissue and the electrode
tip, producing electrical sparks that cause superficial epider-
mal carbonization. This carbon layer has an insulating effect
and minimizes further damage to the underlying dermis. As
a result, lesions treated by electrofulguration usually heal
rapidly with minimal scarring. Because of their low amperage,
electrodesiccation and electrofulguration are best suited for
superficial and relatively avascular lesions, such as verrucae
and seborrheic keratosis. Treatment of highly vascular lesions
often results in a bloody operative field, which quickly
Electrodesiccation
Figure 9.5  Electrodesiccation results in superficial tissue
dehydration. (Adapted from Sebben JE. Electrosurgery. In: Ratz
JL, ed. Textbook of dermatologic surgery. Philadelphia:
Lippincott-Raven; 1998.)
dissipates the heat produced by these low-amperage
modalities.3,8,9
Electrocoagulation
Electrocoagulation uses low-voltage, moderately damped or
partially rectified, high-amperage current in a biterminal
fashion to cause deeper tissue destruction and hemostasis
with minimal carbonization (Fig. 9.7). Low voltage is suffi-
cient to establish current flow since the indifferent electrode
prevents current accumulation in the patient, which would
impede current flow by decreasing the voltage gradient
between electrode and patient. High amperage causes deep
tissue destruction and hemostasis. In electrocoagulation, one
applies and slowly moves the electrode across the lesion until
slightly pink to pale coagulation occurs. A curette may then
be used to remove the coagulum. One should avoid damaging
tissue to the extent that a friable, charred coagulum results,
as this eschar may easily dislodge and result in delayed
bleeding. Coagulated tissue has greater resistance to electrical
current than normal skin, and limits the amount of damage.
The deep destruction provided by electrocoagulation results
in scarring, and should be noted when discussing therapeutic
alternatives with the patient.3,8,9
One may achieve hemostasis by touching the electrode
directly to the bleeding vessel; by first clamping the vessel
with forceps and then transmitting the current through the
forceps by applying the electrode at a more proximal point
Electrofulguration
Figure 9.6  Electrofulguration results in superficial tissue
carbonization. (Adapted from Sebben JE. Electrosurgery. In:
Ratz JL, ed. Textbook of dermatologic surgery. Philadelphia:
Lippincott-Raven; 1998.)

144
Part 2  Essential Surgical Skills
on the forceps; or by using biterminal forceps. The heat gen-
erated seals the vessel by fusion of its collagen and elastic
fibers, and the operative field must be dry for maximal
efficacy. The hemostatic and destructive capacity of electro-
coagulation makes it ideal for the treatment of deeper and
more vascular lesions, for example pyogenic granuloma.3,8,9
Electrocoagulation with biterminal forceps
Colloquially termed ‘bipolar’ electrosurgery, the more techni-
cally correct electrocoagulation with biterminal forceps offers
the advantage of localized electrocoagulation with minimal
current flow beyond the treatment area. These features
are invaluable when the clinical situation demands precise
hemostasis in patients with implantable electrical devices
susceptible to electromagnetic interference, such as cardiac
pacemakers, defibrillators, or deep-brain stimulators (dis-
cussed below). In this approach, each one of the two prongs
of the forceps comprise a treatment electrode, where one tip
may be considered the active electrode and the other the
dispersive electrode, which has been decreased in size to
equal the treatment electrode. Current thus flows almost
exclusively between the tissue spanning these two points,
resulting in very localized tissue damage as well as minimal
current leakage into the patient.13,14
Electrocoagulation
Figure 9.7  Electrocoagulation results in deeper tissue
coagulation. (Adapted from Sebben, JE. Electrosurgery. In: Ratz
JL, ed. Textbook of dermatologic surgery. Philadelphia:
Lippincott-Raven; 1998.)
Electrosection
Electrosection uses undamped or slightly damped, low-
voltage, high-amperage current in a biterminal fashion to
vaporize tissue with minimal peripheral heat damage.
Undamped current yields cutting without coagulation,
whereas slightly damped current provides some coagulation.
The presence of an indifferent electrode permits high current
flow at a relatively low voltage, while the high amperage
allows for highly focused tissue destruction. The precise
mechanism by which continuous, sinusoidal waveforms cut
tissue is unclear, although it may relate to the formation of
explosive microbubbles of steam within tissue cells, or to
direct mechanical cell disruption by electromagnetic wave-
trains. As the majority of the energy dissipates during tissue
vaporization, minimal collateral tissue damage occurs.
Since pure sine waves cut without coagulating, electrosec-
tion using pure sine waves provides no benefit over conven-
tional scalpel surgery. Currents therefore commonly ‘blend’
damped and undamped wavetrains to cause simultaneous
cutting and coagulation. Increasing the voltage increases coag-
ulation by increasing waveform amplitude variability.
A variety of electrode tips are available when applying
cutting current, most commonly including thin wire elec-
trodes, wire loops, and spatulas. When performed correctly,
electrosection requires almost no manual pressure from the
operator as the electrode glides through tissue with minimal
resistance. If sparking occurs, the power setting is likely too
high. If the electrode drags, the power setting is likely
too low.
Advantages of electrosection are its speed and its ability to
simultaneously cut and seal bleeding vessels, for instance in
the excision of large, relatively vascular lesions, such as acne
keloidalis nuchae and rhinophyma. Surgical defects may be
allowed to heal by second intention (Fig. 9.8).2,3,7,15
Electrocautery
Electrocautery uses low-voltage, high-amperage, direct or
alternating current to heat a surgical tip to cause tissue desic-
cation, coagulation or necrosis by direct heat transference to
tissue. Electrocautery is excellent for pinpoint hemostasis and
is compatible with patients who may not tolerate current
flow, for example those with an implantable cardiac pace-
maker or defibrillator. Most destruction with electrocautery
occurs close to the heating element, and is thus more readily
seen and controlled compared to electrosurgery. The Shaw
scalpel is a variation on electrocautery, and consists of a
heated sharp scalpel that simultaneously cuts and coagulates
bleeding vessels.2,3
 OPTIMIZING OUTCOMES
Electrosurgical procedures may be used to treat a diversity
of benign and superficially invasive malignant neoplasms.
Further, electrochemotherapy represents a novel technique
whereby electric pulses increase tumor cell permeability to
chemotherapeutic agents, thus allowing for a targeted antitu-
mor effect that increases efficacy and decreases systemic
toxicity. Appropriate choice of electrosurgical procedure
requires an understanding of the nature of the destructive
modality, histology, and anticipated consequences, including
pigmentary change and scarring (Table 9.2).

145
Chapter 9  Electrosurgery, Electrocoagulation, Electrofulguration, Electrodesiccation, Electrosection
A general therapeutic principle is to use the minimum
power setting necessary to achieve the desired effect. Exces-
sive power causes disproportionate tissue damage, and is
associated with such complications as increased fibrosis, sus-
ceptibility to wound infection, and delayed wound healing.
The treatment electrode should always be clean of carbonized
tissue, which decreases current density and insulates against
current flow, thereby reducing cutting and coagulation effect.
If carbon build up seems rapid and excessive, the power
setting may be too high, or the procedure rate too slow. It is
often useful to combine routine electrosurgery with other
surgical modalities; for example, use of a scalpel, curette, or
scissors to remove the bulk of a large lesion prior to use of
electrosurgery to treat the base. Combination therapy pro-
vides superior control of the depth of destruction, as well as
a specimen for histological examination.4,7,9,11,16
Clinical outcomes in electrosurgery may include such
patient-important outcomes as cure and recurrence rates,
postoperative infection rates, severity of postoperative pain,
and the cosmetic acceptability of the surgical scar. Although
outcomes important to patients are, by definition, important
to physicians, other outcomes may also be important to the
busy dermatologic surgeon, including speed of surgery and
amount of blood loss.
Electrodesiccation and curettage
Electrodesiccation and curettage (ED&C) is a procedure well
known to dermatologists for the treatment of benign and
superficially invasive neoplasms (see Table 9.2). It involves a
sequence of curettage followed by electrodesiccation applied
in two to three repetitions to the lesion. Considerations in
the decision to perform ED&C include assessment of the
depth and histology of the lesion, the thickness of the under-
lying dermis, and the presence of deep-seated hair follicles.
Broad, superficial lesions located in areas with thick under­
lying dermis, such as the trunk and extremities, are ideal
candidates for ED&C. Lesions in these locations are often
clinically well-defined and easily removed by curettage fol-
lowing desiccation, yielding rapid healing and high cure rates.
If one reaches subcutaneous fat during ED&C, the procedure
should be abandoned for excision, as ED&C is less effective
A
B
Figure 9.8  (A) Patient 6 weeks after electrosection removal of acne keloidalis nuchae. (B) At 4.5 months following surgery, the
wound has healed by second intent.
Table 9.2  Potential indications for electrosurgery
TYPE OF LESION
TECHNIQUE
Benign lesions
Acne keloidalis nuchae
Acrochordon
Angioma, cherry
Angioma, spider
Condyloma acuminatum
Dermatosis papulosis
nigra
Molluscum contagiosum
Mucous cysts
Nevi
Oral fibromata
Papilloma
Pyogenic granuloma
Rhinophyma
Seborrheic keratosis
Sebaceous hyperplasia
Syringoma
Telangiectasia
Verruca vulgaris
Verruca plana
S
D, F, S
C, D, F
C
D
D, F
D, F
D, F
S
D, F
D, F
S, C
S
D, F
C
D
C
D
D, F
Premalignant lesions
In-situ squamous cell
carcinoma without
extensive follicular
involvement
Actinic keratosis
D, F
D, F
Malignant lesions
Nodular basal cell
carcinoma
Superficial basal cell
carcinoma
S, D, F
C, electrocoagulation; D, electrodesiccation; F, electrofulguration; S, electrosec-
tion. This list is not comprehensive and electrosurgery may not be the treatment of
choice for each lesion. (Adapted from Zalla M. Basic cutaneous surgery. Cutis
1994;53:172–186,8 Stone S. Electrodesiccation and fulguration of lesions of the
skin. J Fam Pract 1979;8:171–174,12 Sebben J. Electrosurgery. In: Ratz J, ed. Text-
book of dermatologic surgery. Philadelphia: Lippincott-Raven; 1998,16 Roenigk
R, Roenigk H. Current surgical management of skin cancer in dermatology.
J Dermatol Surg Oncol 1990;16:136–151.17)

146
Part 2  Essential Surgical Skills
By contrast, middle-risk sites demonstrated a 5-year recur-
rence of 5% for lesions <10 mm in diameter, whereas lesions
≥10 mm demonstrated almost five times this recurrence rate,
at 23%. In high-risk sites, lesions <5 mm demonstrated an
acceptable 5-year recurrence of 5%, whereas those ≥6 mm
exhibited almost triple the recurrence rate, at 18%. These
differences were statistically significant (P < 0.05). This study
suggests that all lesions occurring in low-risk sites, as well as
any lesion <5 mm (regardless of anatomic site) may be treated
with ED&C with a high probability of cure at 5 years’ follow
up. Lesions ≥10 mm in middle-risk and those ≥6 mm in high-
risk sites, however, exhibit unacceptably high recurrence
rates after ED&C. Excision or Mohs micrographic surgery
may achieve superior outcomes in these cases.20
Cosmetic outcome following ED&C is site dependent. On
the trunk and extremities, ED&C generally results in flat,
white macules or patches, but may occasionally lead to
atrophic, hypertrophic, or even keloidal scars. Several months
usually elapse before the scar attains its final appearance, and,
until this time, may remain pink, pruritic and hypertrophic.
On the face, ED&C heals with a fine white macule or patch,
but may be depressed or produce an indurated, circular scar
from wound contraction. Surgical excision often leads to a
better cosmetic outcome on the face compared to ED&C. In
the study of BCC recurrence following ED&C, 76% of
patients (1285/1691) rated their ED&C scar as ‘good to
excellent’ in terms of cosmesis 1 year after treatment. ED&C
generally provides excellent treatment and cosmetic out-
comes for superficial and nodular BCC, although these results
vary considerably based on anatomic location and lesion
size.18,20
Electrocoagulation
Outcomes relevant to electrocoagulation include hemostasis
and, rarely, surgical incision. Hemostasis should be reserved
for vessels <1 mm; larger vessels or arterioles with a greater
chance of delayed bleeding should be ligated with a dis­
solvable suture. To optimize hemostasis, the operative field
for deeper malignancies. ED&C should be used with caution
in lesions with the potential for follicular extension as recur-
rence risk is higher.18
Basal cell carcinoma
Perhaps the most common indication of electrosurgery is
ED&C for the treatment of basal cell carcinoma (BCC). The
success rate of ED&C is highly operator dependent, as ade-
quate treatment requires that the clinician possesses the
skill to detect subclinical tumor extension by its physical
consistency using the curette. ED&C may be used to treat
nodular and superficial BCC, whereas recurrent or micro­
nodular/morpheaform BCC should be excised because of
their penchant for deep, dermal infiltration. Case series
involving >1000 BCCs report cure rates ranging from 88%
to 99%, although these figures may overestimate benefit as
a result of referral bias and insufficient follow up. Studies
that report the highest cure rates destroy a substantial peri­
pheral margin around the initial curettage, ranging from 2
to 8  mm. Undermined epidermis at the periphery of the
curettage site may be trimmed using scissors.18 One study
summarized all studies of BCC treated by ED&C since 1947
and reported a weighted average 5-year recurrence rate of
approximately 8%.19
Another study reported determinants of 5-year recurrence
rates of 2314 primary BCC treated by ED&C between 1955
and 1982. Multivariate regression analysis established that
patient age, sex, and lesion duration before treatment were
not significant determinants of 5-year recurrence. Increasing
lesion diameter and occurrence in a high- or middle-risk
anatomic site, however, were independent determinants of
5-year recurrence (P < 0.001). High-risk sites include the
nose, paranasal, nasolabial fold, ear, chin, mandibular, peri­
oral, and periocular areas; middle-risk sites include the scalp,
forehead, pre- and postauricular, and malar areas; low-risk
sites include the neck, trunk, and extremities (Fig. 9.9). BCC
in low-risk sites demonstrated an acceptable 5-year recur-
rence rate of 3% after ED&C, irrespective of lesion diameter.
High-risk
region
Middle-risk
region
Low-risk
region
Anterior
Posterior
Risk stratification for
basal cell carcinoma
Figure 9.9  Five-year
recurrence risk for basal cell
carcinoma treated by
electrodesiccation and
curettage depends
significantly on tumor
location. Lesions developing
on the central face, ears,
and mandibular region
exhibit the highest risk.

147
Chapter 9  Electrosurgery, Electrocoagulation, Electrofulguration, Electrodesiccation, Electrosection
between groups for postoperative pain, and wound
complication.
A final RCT compared electrosection versus scalpel incision
for elective midline laparotomy in 100 patients in terms of
incisional time, incisional blood loss, total intraoperative
blood loss, postoperative wound pain, and number of wound
complications. Electrosection was associated with signifi-
cantly quicker incision and less blood loss relative to scalpel
surgery (0.8 mL/cm2 versus 1.7 mL/cm2, respectively; P =
0.002). Electrosection was further associated with signifi-
cantly lower postoperative pain scores 48 hours after opera-
tion, as well as lower total morphine requirements 5 days
after operation relative to scalpel surgery (66 mL vs 92 mL,
respectively; P < 0.05). Wound infection rates were compa-
rable between groups at discharge and at 1 month follow up.25
The results of these RCTs suggest that modern electrosection
units provide superior speed, hemostasis, cosmetic outcome,
and decreased postoperative pain compared to conventional
scalpel surgery, while providing comparable postoperative
wound healing and infection rates.
Electrochemotherapy
Electrochemotherapy refers to the local application of short,
high-voltage, electric pulses to tumor tissue to increase tumor
uptake of local or systemic chemotherapy, and has been
studied most extensively in the context of recurrent, meta-
static, or inoperable cutaneous tumors.26 Hydrophilic chemo-
therapeutic agents, such as bleomycin or cisplatin, are
generally impermeable to the phospholipid bilayer of the cell
membrane because of their hydrophilicity and the absence of
specific channels or receptor-mediated endocytosis.
The basis of electrochemotherapy relies on the strategy of
‘electroporation,’ whereby the phospholipid bilayer of the
plasma membrane that typically restricts entry to hydrophilic
and polar molecules is rendered transiently porous or perme-
able by the application of short, high-voltage electrical field
pulses. These pulses result in the formation of hydrophilic
electropores, wherein adjacent lipid molecules are electrically
reoriented such that their hydrophilic heads comprise the
walls of the pore, and their hydrophobic tails are embedded
in the plasma membrane. This electroporation is transient,
and the plasma membrane resumes its normal architecture
once the electric pulses cease, maintaining cell viability. In
other words, electric pulses possess no intrinsic cytotoxicity
or antitumor effect; they simply allow hydrophilic drugs that
would not otherwise easily penetrate the cell membrane to
enter the cell and induce localized cytotoxicity. This thera-
peutic localization further minimizes systemic toxicity. In
practice, several electrodes are inserted into the target tissue
and optimized pulse parameters for electroporation are deliv-
ered (8 square wave pulses; amplitude 1300 V/cm; duration
10 µs; frequency 1 Hz). This protocol results in such prefer-
ential chemotherapeutic uptake by tumor nodules that a 75%
complete response rate is observed using drug dosages that
have minimal or no antitumor effect in non-electroporated
tissue. The cytotoxicity of bleomycin, for example, is
increased up to 700-fold by this technique.
In addition to direct cytotoxicity, local arteriolar vasocon-
striction mediated by the sympathetic nervous system is
observed within the tumor vasculature in response to the
electric pulses. This vasoconstriction induces a state of
hypoperfusion within the tumor mass that lasts from 12
should be dry, as blood diffuses the current flowing from the
electrode. Care should be taken to apply the minimum
amount of time and power, as well as to clamp only the
minimum amount of tissue necessary to seal the vessel. Lack
of restraint in any of these areas may lead to excess vessel
damage, and increased risk of postoperative bleeding. Another
problem during electrocoagulation is an apparently sudden
decrease in power. Instead of increasing the power setting,
confirm good contact between the indifferent electrode and
the patient to ensure adequate current drain-off, and that
the electrosurgical tip is clean. Incisions made with electro-
coagulation should be avoided as animal studies demon-
strate that they are associated with higher postoperative
infection rates compared to ones made with a scalpel or with
electrosection.7,21
Electrosection
Relevant outcomes include optimizing cutting capacity, as
well as incisional speed, postoperative pain and infection,
wound healing, and scar cosmesis. The most effective cutting
occurs with high current density, which increases as the elec-
trode diameter decreases. A needle electrode thus provides
the most precise cutting effect. Larger electrodes, such as
blades and loops, require greater electrical energy to produce
the same cutting effect, causing greater peripheral tissue
destruction that may impair wound healing. For debulking
procedures, such as rhinophyma excision, a wire loop elec-
trode may be used to remove tissue efficiently. Electrosection
results in more collateral tissue damage compared to scalpel
surgery with some histologic distortion of surgical margins. For
specimens requiring histopathologic analysis, use of a filtered,
fully rectified current (cutting without coagulation) should
be used to prevent significant electrosurgical artifact.11,15
As electrosection may often serve as an alternative to con-
ventional scalpel surgery, it may be important to compare
these modalities with respect to such outcomes as incisional
speed, postoperative pain and infection, wound healing,
and scar cosmesis. Reports of impaired wound healing and
increased postoperative infection rates associated with early
model electrosection units have discouraged the widespread
use of electrosection for skin incision.
Several randomized controlled trials (RCTs) from the sur-
gical literature, however, now compare electrosection against
other incisional modalities in terms of these outcomes. One
RCT compared carbon dioxide (CO2) laser, conventional
scalpel, and electrosection in 88 cholecystectomy patients in
terms of incisional time, incisional blood loss, postoperative
pain, and wound healing. As expected, incisional time and
blood loss were significantly less for electrosection compared
to other modalities (P < 0.05). No statistically significant
difference was observed in the degree of postoperative pain,
the number of wound seromas/infections, and wound
healing.22 It is of interest, however, that animal studies con-
sistently demonstrate slower wound healing with electrosec-
tion compared to scalpel surgery.23,24
Another RCT compared electrosection to scalpel surgery
in 84 patients undergoing inguinal herniorrhaphy or chole­
cystectomy in terms of incisional time, cosmetic outcome,
postoperative pain, and wound complications. Incisions by
electrosection were significantly faster and were associated
with superior cosmetic outcome relative to scalpel incision
(P < 0.01), whereas no significant difference was observed

148
Part 2  Essential Surgical Skills
hours (electropermeabilization alone) to 5 days (electroche-
motherapy). The clinical finding that erosive or ulcerative
skin cancers cease to bleed following electroporation reflects
this vascular effect. Physicians may exploit this vascular
effect by delivering the chemotherapy prior to application of
the electric pulses, such that vasoconstriction within the
tumor mass following electropermeabilization effectively
traps the drug within the electropermeabilized tissue. This
so-called ‘vascular lock’ allows for a highly localized and con-
centrated chemotherapeutic effect.
Lastly, there is evidence to suggest that tumor regression
following electrochemotherapy induces a specific antitumor
immune response. For example, perilesional administration
of interleukin-2 during electrochemotherapy has been shown
to amplify a specific antitumor immune response that induces
regression of untreated tumors at distant sites. Indeed, suc-
cessful palliative reports of electrochemotherapy exist for
recurrent, inoperable, or metastatic melanoma;27 basal cell
carcinoma;28 head and neck, and cutaneous squamous cell
carcinoma;26 and Kaposi’s sarcoma,29 with reported complete
local response rates of 80–90%. The only limitation to the
delivery of this treatment would be the inability to insert the
electrodes into the target tissue. In conclusion, electroche-
motherapy is an effective drug delivery system that may serve
as an adjunct in the treatment of recurrent, inoperable, or
metastatic cutaneous tumors that are not amenable to con-
ventional treatment.26,30
 POSTOPERATIVE CARE
Immediate postoperative care
Superficial electrosurgical wounds heal well by second inten-
tion with basic wound care principles, specifically cleansing
with hydrogen peroxide or saline daily followed by applica-
tion of an ointment and protective dressing. Wounds created
by cutting currents may be sutured, since minimal tissue
damage occurs along the lines of incision. These wounds do
not develop tensile strength as rapidly as scalpel wounds: they
are weaker for 21 days postoperatively, and thereafter exhibit
tensile strength equal to scalpel wounds. A bulky pressure
dressing is advisable as some postoperative bleeding is
expected, normally within 3 days after surgery. A non-
adherent dressing should be placed on the wound surface to
minimize vessel irritation when the dressing is removed 1 or
2 days postoperatively.11,16
Long-term postoperative care
Hypertrophic scarring may complicate healing in a proportion
of electrosurgical wounds. These lesions may be managed
conservatively using massage, and, when appropriate, intra­
lesional corticosteroid injection or pulsed-dye laser.
 PITFALLS AND THEIR MANAGEMENT
n ensure that the indifferent electrode has broad contact
with skin, and is not placed over a bony prominence, scar
tissue, or implanted metal
n ensure patient is not touching grounded metal objects
n consider the risk of current ‘channeling.’
 Electric shock:
n use a three-pronged receptacle that is not overloaded
n do not use treatment table outlet
n surgeon should not make or break contact with patient
during current delivery.
 Transmission of infection:
n use smoke evacuator with intake nozzle 2 cm from
operative site
n wear surgical mask and eye protection when working with
human papillomavirus-related lesions.
 Eye injury:
n avoid using treatment electrode close to eye, if possible
n use corneal shields.
 Cardiac pacemaker and defibrillator malfunction:
Preoperative:
n consider preoperative cardiology consult
n consider alternative therapy in patients who are medically
unstable, pacemaker or defibrillator dependent, or with an
external pacemaker
n consider changing pacemakers to fixed-rate mode
n consider magnetically deactivating implantable
cardioverter–defibrillator during electrosurgery
n avoid cutting current outside the hospital setting.
Operative:
n consider using electrocautery, Shaw scalpel (no current
flow through patient), or biterminal forceps (minimizes
current leakage in patient)
n choose a site far from the heart and pacemaker for
grounding and ensure that the heart does not lie directly in
the path between the treatment and indifferent electrode;
do not work near the heart or pacemaker
n check peripheral pulse and level of consciousness during
electrosurgery
n keep electrosurgical current bursts <5 seconds.
Postoperative:
n consult cardiology to check or reset device.
Although generally safe, electrosurgery is not without risks.
These include electrical burns, electric shocks, infection
transmission, eye injury, and cardiac pacemaker or defibrilla-
tor malfunction.
Electrical burns
Electrical burns reflect concentrated tissue damage when high
current density flows through a small surface area. This sce-
nario arises principally from faulty application of the indiffer-
ent electrode, failure to isolate the patient from metal surfaces
during current application, or from current ‘channeling’ to a
site distant from the treatment area. Faulty application of the
indifferent electrode may include placement over a bony
prominence, scar tissue, or metal implants, or such that only
a small surface area contacts the patient. Current becomes
concentrated in this small surface area, resulting in high
current density. If this application continues for a sufficient
period of time, an electrical burn ensues. If the patient is
conscious, he or she usually complains of pain in the area
Pitfalls and their management2,31–34
 Burns:
n use non-flammable cleanser such as chlorhexidine or
povidone-iodine
n avoid alcohol cleanser, ethyl chloride anesthesia, or use of
flowing oxygen

149
Chapter 9  Electrosurgery, Electrocoagulation, Electrofulguration, Electrodesiccation, Electrosection
mize the risk of electrical burns. As inadvertent activation of
the treatment electrode may cause burns, the active electrode
should never be left on the patient while not in use. An
attempt should be made to ensure approximately 20 square
inches of surface contact area for the indifferent electrode,
as this is usually sufficient for current dispersion. Use of
modern, indifferent electrodes that are sufficiently flexible to
conform to the body as well as the use of a protective inter-
face gel may minimize the risk of faulty application. The
indifferent electrode should not be cut to the desired size or
bent, as this decreases the dispersion area and may create
sharp points where current concentration may occur. The
surgical staff should ensure that the patient is not in contact
with any grounded metal object. Current channeling is rare
at normal power settings. The risk may be further mini-
mized by using ‘bipolar’ forceps, an indifferent electrode, or
by increasing the cross-sectional area of current flow, for
example by wrapping a saline-soaked sponge (an electrolyte
conductor) around the narrow base of the mass being
treated.2,4,31
Electrocution and electric shocks
Electrocution results from electrically-induced ventricular
fibrillation, and is most likely when a low-resistance path
directly delivers current to the heart. The risk of electrocu-
tion with modern electrosurgical units is minimal as trans-
formers separate the treatment electrodes from the power
source, and, in the event of unit malfunction, a three-pronged
grounding plug diverts any current leakage to ground.
In cases where no indifferent electrode is used, the patient
becomes a receptacle for static electricity and may deliver
painful electric shocks to nearby grounded persons. To
minimize the risk of electric shock, the staff should not
make or break contact with the patient during current
application.16
Infection transmission
Some physicians believe that the heat induced by electrosur-
gery sterilizes the electrode tip. Although this statement is
true for electrocautery, it does not apply to electrosurgery,
where heat production occurs in tissue only. Electrosurgery
thus carries the potential of transferring surface bacteria
and viruses to the surgical wound. In experimental settings,
electrodesiccation has been associated with transmission of
hepatitis B virus, human papillomavirus (HPV), and Staphy-
lococcus aureus, although reported wound infection rates
remain low. HPV may become aerosolized in blood micro-
droplets and in electrosurgical smoke, with potential trans-
mission to the patient and the surgical staff. To minimize
these risks, disposable or sterilized treatment electrodes and
protective covers for electrode handles should be used for
each procedure. A smoke evacuator, facial masks, and protec-
tive eye wear should be used whenever treatment involves
HPV-related lesions or creates a smoke plume.10,17,32
Eye injury
When electrosurgery is performed in the periorbital region,
sparks may arc towards the globe and result in corneal damage
and scarring. When possible, one should avoid electrosurgery
in this area, or apply special corneal shields to protect the
eyes.16
before the burn occurs; however, complaints of pain are
impossible under general anaesthesia, resulting in increased
risk.
Burns may also occur if the patient touches a grounded
metal object, particularly if the indifferent electrode is in
poor contact or is broken. In this case, the current seeks any
alternative low-resistance pathway from the patient to the
ground; a burn results from current concentration through a
small surface area in contact with the metal object. Common
hazards include an electrocardiogram needle or plate, intra-
venous pole, rectal temperature probe, or photocell ear
plethysmographs.
Finally, current may concentrate as it flows through a small
area, a phenomenon known as current ‘channeling.’ This
problem occurs when current is applied to a mass with a
narrow stalk or base, leading to current concentration when
it traverses this narrowed region. Current flowing through
a large papilloma with a thin stalk may concentrate and
cause a burn at its base. Channeling may also occur when
current contacts tissue, such as nerve or a vessel, which is
more conductive than the surrounding tissue. The resultant
distant coagulation occurring in a nerve or a vessel may have
grave consequences when it occurs in an isolated region,
such as the finger or the penis. Current channeling has
been reported on the scrotum with subsequent necrosis
(Fig. 9.10).2,4
Reports of burns during electrosurgery are uncommon in
dermatology, and most events stem from the surgical litera-
ture. Certain precautionary measures may nonetheless mini-
Penile shaft
Treatment electrode
Indifferent electrode
Current concentrates
in narrow region
Channeling of electrosurgical current
Figure 9.10  Current channeling leads to current concentration
in narrowed regions, such as the base of the scrotum. The
increased current density may result in electrical burns and
tissue necrosis.

150
Part 2  Essential Surgical Skills
drug toxicity. Electrosection poses the greatest risk for pace-
maker-related complications, but these may occur with all
electrosurgical procedures.32,35
An ICD is a device that sends a defibrillatory shock to the
heart when it senses ventricular fibrillation or tachyarrhyth-
mia. It is indicated for refractory ventricular tachyarrhyth-
mias, and consists of a sensing circuit and current generator
inserted in an abdominal or infraclavicular subcutaneous
pocket. The sensing circuit of the ICD may misinterpret
electrosurgical output as a tachyarrythmia or as ventricular
fibrillation. As a result, it may erroneously deliver a defibril-
lating shock to the heart, which may in turn induce true
tachyarrhythmia. Permanent ICD damage may also result if
the interference is sufficient.32
A deep-brain stimulator is an implantable device that gen-
erates electrical impulses to control movement disorders,
such as essential tremor or the tremor of Parkinson’s disease,
that are refractory to pharmacologic therapy. An electrode is
stereotactically placed in the subthalamic nucleus contralat-
eral to the side with the severest tremor symptoms, and
connected by a wire to a pulse generator typically placed in
the subcutaneous tissue of the chest, similar to a cardiac
pacemaker. The electrical pulses counteract faulty brain sig-
naling that induces tremor. Similar to cardiac devices, elec-
trosurgery may interfere with the function of deep-brain
stimulators, resulting in lancinating pain in the neuroana-
tomical distribution of the electrodes.36,37 Some patients may
also exhibit hemitetany and self-limited, postictal behavior
following electromagnetic interference of their deep-brain
stimualtor (N Annest MD, personal communication, Novem-
ber 19, 2008).
Given the potential severity of these complications, the
question of their frequency becomes a pressing issue. A
survey study of 166 Mohs surgeons with a total of 1959 years
of experience determined the number and type of complica-
tions due to electrosurgery in the dermatologic setting. This
study reported an exceedingly low incidence of interference
(1.6 cases/100 years of surgical practice) and of clinical
adverse events (0.8 cases/100 years of surgical practice), with
no significant morbidity or mortality. Twenty-five cases of
interference were reported, consisting of skipped beats (8
patients), pacemaker reprogramming (6 patients), ICD firing
(4 patients), asystole (3 patients), bradycardia (2 patients),
shortened battery life (1 patient), and tachyarrhythmia (1
patient). Of these 25 cases, 18 patients experienced a clinical
adverse outcome: syncope (6 patients), altered sensorium (5
patients), palpitations (3 patients), outpatient cardiology
consult (3 patients), and hemodynamic instability (1 patient).
Cardiac pacemaker, defibrillator, or
deep-brain stimulator malfunction
High-frequency electrosurgery may interfere with cardiac
pacemaker, implantable cardioverter–defibrillator (ICD), or
deep-brain stimulator function, with the potential for patient
fatality. Pacemakers may be classified as either fixed rate, in
which the pacemaker fires at a predetermined rate irrespec-
tive of intrinsic cardiac rhythm, or demand-type, in which
the pacemaker fires at a predetermined rate in the absence
of intrinsic cardiac rhythm. Demand-type pacemakers are
further classified as either ‘ventricular inhibited’ or ‘ventricu-
lar triggered.’ The most common pacemaker in the US is the
ventricular-inhibited, demand-type pacemaker. Pacemaker
types and potential complications are summarized in
Table 9.3.
Fixed-rate pacemakers have no sensing circuitry, and thus
resist interference from extraneous electrical signals. All
demand pacemakers have sensing circuitry, and are thus sus-
ceptible to this type of interference. A ventricular-inhibited,
demand pacemaker does not fire in the presence of sensed
ventricular contraction. In the absence of sensed ventricular
depolarization, it generates an impulse to stimulate ventricu-
lar contraction, thus preventing bradycardia or asystole. Ven-
tricular-triggered units, by contrast, stimulate ventricular
contraction with each sensed ventricular depolarization. Since
the ventricles have already depolarized, no signal capture and
no effect on the heart occurs. In the absence of sensed
ventricular depolarization, it generates an impulse to stimu-
late ventricular contraction, thus preventing bradycardia or
asystole.31,35
In the context of electrosurgery, the sensing circuitry of
demand pacemakers may misread the electromagnetic output
of electrosurgery as spontaneous ventricular contraction. The
cardiac sequelae of this misinterpretation depend on whether
the pacemaker is of the ventricular-inhibited, or ventricular-
triggered type. In the former, the unit misreads the electro-
surgical signal as a spontaneous heartbeat, and erroneously
enters stand-by mode. In patients who are pacemaker depend-
ent, this malfunction may result in profound bradycardia or
asystole, with syncope, seizures, and death. In the latter, the
unit misreads the electrosurgical signal as a spontaneous
heartbeat, which triggers it to erroneously stimulate ventricu-
lar contraction. This output may result in extrasystole, or in
life-threatening tachyarrhythmias or ventricular fibrillation
should it occur during the vulnerable cardiac repolarization
period. Risk of arrhythmia is low in healthy individuals, but
increases with myocardial anoxia, electrolyte imbalance, or
Table 9.3  Effect of electrosurgical interference on pacemaker function31
PACEMAKER TYPE
FUNCTION
CONSEQUENCE OF
ELECTROSURGICAL INTERFERENCE
Fixed rate
Fires at predetermined rate irrespective of intrinsic cardiac
rhythm
No effect
Demand:
Ventricular inhibited
Fires when intrinsic cardiac rhythm is slower than preset rate
Bradycardia, asystole
Ventricular triggered
Fires with each spontaneous heartbeat; in the absence of
intrinsic rhythm, fires at predetermined rate
Extrasystole, tachyarrhythmia, ventricular
fibrillation

151
Chapter 9  Electrosurgery, Electrocoagulation, Electrofulguration, Electrodesiccation, Electrosection
invasive malignant neoplasms with minimal blood loss, and
represents an important procedure for dermatologic surgery.
 REFERENCES
1. Wagner R, Tomich J, Grande D. Electrolysis and thermolysis for perma-
nent hair removal. J Am Acad Dermatol 1985;12:441–449.
2. Bennett R. Electrosurgery. In: Bennett R, ed. Fundamentals of cutaneous
surgery. St Louis: CV Mosby 1988; 553–590.
3. Boughton R, Spencer S. Electrosurgical fundamentals. J Am Acad
Dermatol 1987;16:862–867.
4. Schellhammer P. Electrosurgery: principles, hazards, and precautions.
Urology 1974;3:261–268.
5. McCarthy J. Electrosurgery. In: McAinsh T, ed. Physics in medicine and
biology encyclopedia. New York: Pergamon Press 1986; 319–323.
6. Jensen T. Physics for the health professions, 3rd edn. New York: John
Wiley & Sons; 1982.
7. Pollack S, Grekin R. Electrosurgery and electroepilation. In: Roenigk R,
Roenigk H, eds. Dermatologic surgery: principles and practice. New
York: Marcel Dekker 1989; 187–203.
8. Zalla M. Basic cutaneous surgery. Cutis 1994;53:172–186.
9. Sebben J. Electrosurgery: high-frequency modalities. J Dermatol Surg
Oncol 1988;14:367–371.
10. El-Gamal H, Dufrersne R, Saddler K. Electrosurgery, pacemakers, and
ICDs: a survey of precautions and complications experienced by cutane-
ous surgeons. Dermatol Surg 2001;27:385–390.
11. Sebben J. Electrosurgery principles: cutting current and cutaneous
surgery – part II. J Dermatol Surg Oncol 1988;14:147–150.
12. Stone S. Electrodesiccation and fulguration of lesions of the skin. J Fam
Pract 1979;8:171–174.
13. Sebben J. Monopolar and bipolar treatment. J Dermatol Surg Oncol
1989;15:364–366.
14. Sebben J. Electrodes for high-frequency electrosurgery. J Dermatol Surg
Oncol 1989;15:805–810.
15. Sebben J. Electrosurgery principles: cutting current and cutaneous
surgery – part I. J Dermatol Surg Oncol 1988;14:29–31.
16. Sebben J. Electrosurgery. In: Ratz J, ed. Textbook of dermatologic
surgery. Philadelphia: Lippincott-Raven 1998; 457–472.
17. Roenigk R, Roenigk H. Current surgical management of skin cancer in
dermatology. J Dermatol Surg Oncol 1990;16:136–151.
18. Goldmann G. The current status of curettage and electrodesiccation.
Dermatol Clin 2002;20:569–578.
19. Rowe D, Carroll R, Day C. Long term recurrence rates in previously
untreated (primary) basal cell carcinoma: implications for patient follow-
up. J Dermatol Surg Oncol 1989;15:315–328.
20. Silverman M, Kopf A, Grin C, et al. Recurrence rates of treated basal
cell carcinomas. Part 2: curettage-electrodesiccation. J Dermatol Surg
Oncol 1991;17:720–726.
21. Kim H, Brunner E, Ritter E, et al. Relevance of methods of skin incision
technique on development of wound infection. Am Surg 1991;57:
129–130.
22. Pearlman N, Stiegmann G, Vance V, et al. A prospective study of inci-
sional time, blood loss, pain and healing with carbon dioxide laser, scalpel
and electrosurgery. Arch Surg 1991;126:1018–1020.
23. Hambley R, Hebda P, Abell E, et al. Wound healing of skin incisions
produced by ultrasonically vibrating knife, scalpel, electrosurgery,
and carbon dioxide laser. J Dermatol Surg Oncol 1988;13:1213–
1217.
24. Fry T, Gerbe R, Botros S, et al. Effects of laser, scalpel, and electrosurgi-
cal excision on wound contracture and graft ‘take’. Plast Reconstr Surg
1980;65:729–731.
25. Kearns S, Connolly E, McNally S, et al. Randomized clinical trial of
diathermy versus scalpel incision in elective midline laparotomy. Br J Surg
2001;88:41–44.
26. Marty M, Sersa G, Garbay J, et al. Electrochemotherapy: an easy
highly effective and safe treatment of cutaneous and subcutaneous
metastases. Results of ESOPE (European Standard Operating Proce-
dures of Electrochemotherapy) study. Eur J Cancer 2006;4(Suppl):
3–13.
27. Quaglino P, Mortera C, Osella-Abate S, et al. Electrochemotherapy with
intravenous bleomycin in the local treatment of skin melanoma metas-
tases. Ann Surg Oncol 2008;15:2215–2222.
28. Fantini F, Gualdi G, Cimitan A, et al. Metastatic basal carcinoma with
squamous differentiation: report of a case with response of cutaneous
metastases to electrochemotherapy. Arch Dermatol 2008;144:1186–
1188.
29. Curatolo P, Mancini M, Ruggiero A, et al. Successful treatment of penile
Kaposi’s sarcoma with electrochemotherapy. Dermatol Surg 2008;34:
839–843.
There are two reports of deep-brain stimulator interference.36
The most common electrosurgical procedures associated with
interference, in order of increasing frequency, were electro­
fulguration, electrosection, electrocoagulation, and electro­
desiccation. The safety record of electrosurgery in the
dermatologic setting thus appears to be excellent, with no
significant reports of morbidity or mortality.10
Fortunately, pacemaker technology has kept pace with the
potential for interference with electrosurgical devices. Most
modern pacemakers are designed with metallic covers and
filters that minimize the risk of pacemaker malfunction
by effectively rejecting extraneous electrical interference.
Several authors have also recommended precautionary meas-
ures when approaching a patient with a pacemaker, ICD,
or deep-brain stimulator as a candidate for electrosurgery
(see Pitfalls and their management box, above). Although
these guidelines are excellent, the low incidence of complica-
tions in the dermatologic setting suggests that they should
not be followed categorically, but tailored to the clinical
scenario.
 SUMMARY
Electrosurgery refers to a procedural class that uses tissue
resistance to the passage of high-frequency, alternating
current to generate thermal tissue damage. These treatments
range from superficial tissue dehydration, as in electrodesic-
cation and electrofulguration; deep tissue coagulation, as in
electrocoagulation; to tissue cutting, as in electrosection.
Electrocautery is not a true form of electrosurgery as no
current flows through the patient. The precise effect of elec-
trical current on tissue depends on such electrical concepts
as current density, resistance, voltage, power, and waveform
output. Electrosurgical units increase the amperage and fre-
quency of the available current, and modify its waveform
to that appropriate for the clinical indication. Spark-gap
units are most commonly used for electrodesiccation, elec-
trofulguration, and electrocoagulation, whereas vacuum-tube
units are used for electrosection. The waveform output of
both, however, may be modified by adjusting their oscillating
units.
Electrosurgery may be indicated for a variety of benign and
superficially invasive malignant neoplasms. ED&C is one of
the most effective treatments for superficial and nodular
BCC, although cure rates depend significantly on the lesion
size, histology, and anatomic location. Recent RCTs from the
surgical literature suggest that modern electrosection units
provide superior speed, hemostasis, cosmetic outcome, and
postoperative pain compared to conventional scalpel surgery,
while providing similar postoperative wound healing and
infection rates. Electrochemotherapy is an effective drug
delivery approach in the setting of recurrent or inoperable
cutaneous malignancies that uses electric pulses to increase
tumor cell membrane permeability to impermeant chemo-
therapeutic drugs, particularly bleomycin.
Potential adverse events associated with electrosurgery
include electrical burns, electric shock, infection transmis-
sion, eye injury, and pacemaker, ICD, and deep-brain stimu-
lator malfunction. The incidence of these adverse events,
however, is relatively low.
In the correct clinical context, electrosurgery provides a
rapid, efficacious means of treating benign and superficially

152
Part 2  Essential Surgical Skills
34. Hainer B, Usatine R. Electrosurgery of the skin. Am Fam Physician
2002;66:1259–1266.
35. Krull E, Pickard S, Hall J. Effects of electrosurgery on cardiac pace­
makers. J Derm Surg 1975;1:43–45.
36. Weaver J, Kim S, Torres A. Cutaneous electrosurgery in a patient with
a deep brain stimulator. Dermatol Surg 1999;25:415–417.
37. Martinelli P, Schulze K, Nelson B. Mohs micrographic surgery in
a patient with a deep brain stimulator: a review of the literature
on implantable electrical devices. Dermatol Surg 2004;30:1021–
1030.
30. Corovic S, Al Sakere B, Haddad V, et al. Importance of contact surface
between electrodes and treated tissue in electrochemotherapy. Technol
Cancer Res Treat 2008;5:393–399.
31. Sebben J. Electrosurgery and cardiac pacemakers. J Am Acad Dermatol
1983;9:457–463.
32. LeVasseur J, Kennard C, Finley E, et al. Dermatologic electrosurgery in
patients with implantable cardioverter–defibrillators and pacemakers.
Dermatol Surg 1998;24:233–240.
33. Aigner N, Fialka C, Fritz A, et al. Complications in the use of diathermy.
Burns 1997;23:256–264.

153
10
Cryosurgery
Paola Pasquali MD, Günther J Sebastian MD, and Christos C Zouboulis MD PhD
Summary box
 A surgical treatment option for benign and malignant lesions.
 Excellent safety profile and relatively easy to perform.
 A low-cost procedure of short duration.
 Less invasive and has a lower morbidity than some other
surgical procedures.
 Usually performed as an outpatient procedure.
 Applicable for elderly patients with comorbid diseases that
limit the ability to perform invasive surgery, and for pregnant
patients.
 Good to very good cosmetic results.
 Limited complications with few contraindications.
 INTRODUCTION
Cryosurgery is a surgical method using the application of low
temperatures to living tissue, resulting in tissue destruction.
It is an extremely valuable alternative to more invasive surgi-
cal options because of its cost-effectiveness, excellent aes-
thetic results, and rapid delivery. With proper training,
common skin diseases can be treated in a variety of settings,
such as ambulatory surgical areas, doctors’ offices, and nursing
homes.
Basic principles
The basic cryosurgery principle is that of freezing cycles with
subzero temperatures that result in sloughing of the damaged
tissue and subsequent healing by second intention. From a
biological perspective, subzero temperatures cause cellular
structural changes that result in cell death. Cell destruction
occurs due to:
• The physical effect of direct cell injury with water
crystalizing outside the cell. The initially hyperosmotic
extracellular fluid causes water to move out of the cell
by osmosis, with internal dehydration and subsequent
membrane and organelle damage. Further freezing
causes internal crystal formation and cell bursting. As
thawing begins, ice crystals reorganize inside the cell,
forming larger crystals and further cell destruction. The
melting outside the cells reverses water movement, now
from outside to inside, with cell swelling and disruption
of membranes. Additional freezing after the first
freeze–thaw cycle causes further cellular damage. With
more freeze–thaw cycles, there is greater cell damage.
• A vascular effect with initial vasoconstriction, blood
stasis, and cellular anoxia. Once thawing ends, there is a
compensatory vasodilatation that brings in free radicals
and causes further cell damage.
• The immunologic effect. Some investigations suggest a
positive immune response after cryosurgery while others
show the opposite.1
Necrosis occurs at the center of the area of destruction where
the temperature is consistently less than −40°C. At the edge
of the treated area, there is a rim of partially damaged tissue
where temperatures between 0°C and −40°C are obtained.
In the peripheral areas, some cells die and others remain alive
but sustain sufficient injury to trigger apoptosis as the final
mechanism of cell death at the peripheral border with intact
tissue.2–5
Knowing the temperature at the center of the lesion helps
the cryosurgeon to ensure that adequate freezing is achieved.
Thermocouples inside the lesion (thermometry) and elec-
trodes around the tissues (impedancemetry) can be used to
monitor the temperature. More recently, an infrared sensor
attachment (e.g. Cry-Ac®Tracker®) can be placed at the
probe tip and measures the temperature attained as the spray
exits.
For the experienced cryosurgeon, delivery time is the
parameter most likely to be used to determine freezing. Rapid
freezing is ideal because it ensures cell death. Osmotic water
movement achieves cell death more slowly by internal crys-
talization, cell expansion, and the rupture of cellular struc-
tures. Slow thawing extends the time the tissue is kept at low
subzero temperatures and increases the probability of intra-
cellular ice formation and resultant cellular damage. Rapid
freezing with slow thawing is the ideal formula for cell
destruction. A single freeze–thaw cycle is reserved for benign
flat lesions; repeated cycles are used for bulky benign or
malignant lesions.
Conductivity of the material interposed between the lesion
and the cryogen will determine the final freezing temperature
as well as the speed of attaining it. Air is a poor thermal
conductor, water is better, and ice is much better. Some
metals, such as copper, are ideal thermal conductors; there-
fore, freezing with copper as a conductor results in rapid
low-temperature freezing. The practical application of this

154
Part 2  Essential Surgical Skills
the first commercially available hand-held cryosurgical
device.8,9 Cryosurgery soon became one of the most com-
monly used surgical techniques worldwide.
 TECHNICAL ASPECTS
AND TECHNIQUES
Equipment
Cryosurgery uses cryogens as freezing substances. Cryogens
need to be stored safely and applied to the lesion in a safe,
practical, and relatively simple way. Many different sub-
stances have been tried as cryogens, including nitrous oxide,
helium, freons, fluorocarbonated sprays, liquid nitrogen, and
solid carbon dioxide. While solid carbon dioxide achieved
popularity in the early 20th century, it does not achieve
temperatures below −79°C. Over the years, liquid nitrogen
was widely accepted as the ideal cryogen because of trans-
portation safety, low cost, ease of storage, and low tempera-
ture (−196°C), which achieves ideal freezing temperatures
needed to destroy malignancies. The goal of treatment is to
obtain temperatures of −50°C to −60°C at the periphery of
the ice ball. In this chapter, the ’cryogen’ refers to liquid
nitrogen.
Storage tanks for liquid nitrogen are commercially available
in capacities of 4, 5, 10, 25, 30, 35, and 50 liters. They are
constructed with insulating material and covers to provide
long holding times (Fig. 10.1). Gloves, tank stands, and with-
drawal devices help facilitate handling of the cryogen. Over
the years, cryosurgical units have evolved from heavy, diffi-
cult-to-handle bottles to low-cost, highly efficient, low-
weight, hand-held, easy-to-use devices. Even small units hold
concept is that the greater the distance between the tip of
spray and the lesion, the less freezing occurs. If a large amount
of keratin is present over the lesion, such as in hyperkeratotic
tumors, there is less freezing due to the poor conductivity
properties of keratin. Factors affecting freezing in tissue are
summarized in Table 10.1.
Research has explored high-resolution ultrasound for diag-
nosis,6 and monitoring treatment and follow up. In addition,
confocal microscopy,7 nuclear magnetic resonance and, in the
near future, newer-generation microscopes like multiphoton
and harmonic generation microscopes may aid in exploring
the cellular response to cryosurgery.
Historical vignette
Since ancient times, cold has been used for medical purposes.
It was first applied as a local anesthetic and to diminish
malignant tumor pain and size.
The first substance tried as a cryogen was ice, and then salt
and water solutions were mixed with crushed ice. By 1885,
the observation that atmospheric gases warm when com-
pressed and cool when expanded led to the use of liquified
oxygen, hydrogen, and nitrogen as cryogens. In the early 20th
century, cold was used to treat dermatological lesions with
different methods and cryogens, among them carbon dioxide
(dry ice) and liquid nitrogen-soaked cotton applicators, with
variable results.
In the 1960s, Zacarian and Adham increased the depth of
destruction by using copper disks immersed in liquid nitro-
gen, taking advantage of copper’s excellent thermal conduc­
tance properties. The breakthrough in cryosurgery came in
1961 when Cooper and Lee introduced an automated appa-
ratus that used liquid nitrogen in a closed system. Heat could
now be extracted from tissue in a controlled manner.
Dermatologists developed this technique with Torre,
Zacarian, Adham, and Garamy introducing cryosurgery into
the dermatologist’s office. In 1968, Michael Bryne developed
Table 10.1  Factors affecting freezing in tissue
BENIGN
LESIONS
MALIGNANT
LESIONS
Speed of tissue
freezing
Moderate or rapid
speed (≤100°C or
>100°C/min)
Rapid speed
(>100°C/min)
Speed of thawing
Slow speed (10°C/
min or spontaneous
rewarming)
Slow speed
(10°C/min or
spontaneous
rewarming)
Intra-/extracellular
osmotic phenomena
Heterogeneous and/
or homogeneous
nucleation
Homogeneous
nucleation
Probe tip temperature
−86°C or −196°C
−196°C
Tissue temperature
−20°C to −25°C
−50°C or lower
Duration of freezing
30 seconds
30–60 seconds
Repetition of freeze–
thaw cycles
No
Yes (twice)
Vascular reaction
Yes
Yes
Immunologic reaction
Probable
Probable
Figure 10.1  Storage tank and hand-held units.

155
Chapter 10  Cryosurgery
The spray is released though an orifice into a metal chamber,
which is firmly applied to the skin. The liquid nitrogen comes
out of the unit and is trapped within this chamber where its
turbulent movement lowers the temperature of the cryogen
even further. Chambers have to be used with extreme caution
because lower temperatures are achieved faster. We limit the
use of chambers to malignancies, such as squamous cell car-
cinomas, and for palliative cryosurgery.
Closed technique
The closed technique uses probes to deliver the liquid nitro-
gen from the unit via a conduit line that maintains a closed
system. Probes are built up with metal, usually copper, and
are available in different shapes and sizes. Ideally, the probe
should fit the shape of the lesion, which means the cryosur-
geon will have many probe shapes. If the cryosurgeon does not
have the right size of probe, a valuable rule of thumb is to
choose one that is smaller than required rather than a larger
one. Using a smaller probe allows the surgeon to let a larger
visible freezing front develop and avoids freezing healthy
tissue.
Many probes have Teflon on the outer surface to avoid
undesirable sticking to the area, which will pose a risk of
inadvertently breaking the tissue with sudden movement of
the unit. Tissue adherence can also be reduced by freezing
the probe before contact with the skin, which is very useful
when treating hemangiomas or mucosal lesions. If the probe
adheres to the surface, abundant warm water facilitates
detachment. Never force a probe away from a frozen sur­
face because the tissue can fragment, resulting in profuse
bleeding.
Care should be taken when using probes since the cold
vapor emitted from the release hose could inadvertently burn
the patient. To avoid this risk, point the open end of the hose
away from the patient.
Intralesional technique
A method for applying deep cryosurgery was developed by
Weshahy11 and modified by Zouboulis et al12 and Har-Shai
et al.13 Ideally for voluminous or deep-seated tumors, it con-
sists of inserting one or several sterile open cannula probes,
or sterilized, closed, double cannula probes into one side of
the tumor and running it interstitially along the largest axis
of the lesion at its deepest point until it appears on the
surface at the opposite tumor border. The cannulae can be
angled, turned, or hooked. Liquid nitrogen is then sprayed
into the cannula. An ice cylinder is formed around the embed-
ded part of the cannula within the core of the lesion.
The main advantage of intralesional cryosurgery is the
minimal surface destruction compared with the previously
mentioned techniques.
Preoperative preparation
The minimal preoperative care required makes cryosurgery
particularly useful and practical for the treatment of patients
who have difficulty lying down on the examination table; are
in a wheelchair; cannot leave their home or nursing home; or
have difficulty returning to the office. Cryosurgery is a surgi-
cal technique that can be carried out in a wide variety of
settings and does not require a special surgical area.
sufficient cryogen to freeze many small lesions or a few large
ones.
Techniques
The various techniques of cryosurgery include:
• Open (or spray)
• Chamber (also considered a variant of the open
technique) (Fig. 10.2)
• Closed (contact or probe) (Fig. 10.3)
• Intralesional.
Open technique
In the open technique the cryogen is released from the unit
through tips, needles, a cannula, or cones. Tips come in dif-
ferent diameters – A (the largest), B, C, or D (the smallest)
or with numbers 1, 2, 3, 4. Important factors in determining
the amount of cold applied to an individual lesion are the tip
diameter, intermittent release of the cryogen, and distance
from tip to target. Dr. Graham established spraying time
guidelines based on intermittent spray released through a B
tip, with a seborrheic keratosis requiring from 8 to 15 seconds
and a basal cell carcinoma from 60 to 120 seconds.10
Cones are available in different sizes and are made of
rubber, neoprene, or plastic. They contain the sprayed liquid
nitrogen within a defined area, allowing monitoring of the
advance of the freeze front beyond the outside wall of the
cone. A plastic disk with four cone-shaped openings of 0.3,
0.5, 0.8, and 1 cm is also available.
Chamber technique
The chamber technique is a variation of the open technique.
Chambers are commercially available in different diameters.
Figure 10.2  Different types of chambers.
Figure 10.3  Different types of probes.

156
Part 2  Essential Surgical Skills
General principles
• For benign lesions, it is better to undertreat and then
repeat treatment with a second procedure than to
overtreat and leave hypochromia or a scar.
• To improve cold penetrance, excessive keratin should be
removed.
• If using probes, be careful not to forcibly remove a
probe stuck to a surface. Always allow thawing and
gently remove the probe.
• Irregular surfaces are better treated with spray. In
flatter or smoother surfaces, probes can be applied.
• Avoid using cotton swabs for cryosurgery. It is an
obsolete method and temperature control is
completely lost. Cotton swabs have poor thermal
capacity and there is a real risk of achieving suboptimal
temperatures.
• Work on bloodless areas. Hemostatic substances,
such as aluminum chloride, stop bleeding prior to
cryosurgery. This is extremely important because blood
rapidly increases the local temperature. Trichloroacetic
acid, although an excellent hemostatic, should be used
with caution because the white halo formed as a result
of protein precipitation can be confused with the
advancing freezing front.
• Probes should be used in vascular lesions like
hemangiomas and most vascular malformations.
• Cartilage and bone are very resistant to freezing.
• Melanocytes are very sensitive.
 PRACTICAL APPLICATIONS
Many diseases can be treated with cryosurgery (Table 10.2).
As a surgical technique, cryosurgery can be used whenever it
is necessary to eliminate or destroy tissue; proper training and
experience will allow the surgeon to decide when cryosurgery
is the best choice of treatment.
The most common conditions treated with cryosurgery and
some for which cryosurgery can be considered as a first option
are described below.
Human papillomavirus infection
Human papillomavirus lesions, in their many clinical forms,
are very sensitive to cryosurgical treatment. Many lesions can
be treated in one single session with excellent results. It is
probably the most frequently used dermatologic technique.
Better results can be obtained by the use of correct freezing
technique.
For verrucas, reduce keratin first by shaving or using kera-
tolytic substances for a few weeks before cryosurgery. Wet
the area before spraying to increase cold conductivity. Use
anesthesia only on large lesions. One single-cycle spray with
a B or C tip is used with the freezing front advancing just a
few millimeters outside the lesion. The use of cones can
define the area to be treated.
For multiple condylomata, topical anesthesia can be used.
If the lesions are few and dispersed, avoid the pain of an
injection by pretreating the lesions with topical anesthesia.
Cryosurgery is well tolerated in the genital and perianal areas.
If lesions on the penis are located all around the shaft, freez-
ing should not be done around the total circumference to
avoid pseudophymosis caused by postcryosurgical edema. In
Cryosurgery can also be applied safely to patients with
underlying medical conditions, such as bleeding problems,
heart conditions, and metabolic diseases. Large malignant
lesions can safely be treated without having to expose a
debilitated patient to the risk of bleeding. It also reduces the
risk of blood contact when treating a patient with a blood-
borne infection such as hepatitis or HIV as, in the closed
technique, probes are protected by a rubber sleeve.
Preoperative assessment includes the patient’s skin type
and lesion thickness. Some skin types tend to be more sensi-
tive to cold; thus, the reactions can be more severe. More
keratinized and thicker lesions need to be treated for a longer
period of time. Cold tolerance is variable from person to
person and difficult to assess until exposure to the cold is
experienced. When treating multiple lesions, apply cold to
one or two areas and observe the patient’s tolerance. For
multiple superficial lesions, patients who tolerate subzero
temperatures might feel less pain if treatment is given without
local anesthesia. Multiple lidocaine injections can be more
painful than local tissue freezing because cold is slightly anes-
thetic in itself. Pain can be more intense during the thawing
rather than the freezing stage. Curiously, thawing pain is not
necessarily reduced by using anesthesia, while freezing pain
is. Topical anesthesia may be applied by the patient at home
prior to the procedure and can be considered for large treat-
ment areas.
Preoperative diagnosis may include a skin biopsy. Once the
nature, location, and thickness of the lesion are known, the
surgeon can decide on the technique, freezing time, and
freezing depth that are required. If cryoglobulinemia is sus-
pected, laboratory testing is required. Other tests may include
dermatoscopy, ultrasound, radiography, magnetic resonance
angiogram with contrast enhancement (particularly useful in
vascular tumors), and computed tomography scans.
All patients should be informed, verbally and in writing, of
the expected postoperative course, which may help to avoid
unnecessary anxiety. For very anxious patients, anxiolytic
medication may be prescribed to be taken the night before,
and a pain reliever given just before the procedure.
For children, the caregiver should be advised that the child
should not eat for at least 3 hours prior to the procedure. If
necessary, the child can be sedated with oral chloral hydrate
and local anesthesia applied to the base of the lesion. A baby
should be fed immediately after the procedure, as a feed can
be the best postoperative anesthesia!
In order to protect vital areas such as the eye, mouth, or
genitalia, avoid the use of metal devices as they are excellent
cold conductors and may adhere to the area. Use plastic or
wood retractors, goggles, and cotton for procedures in the ear
or nose canals. A basic surgical kit consisting of curette, scissors,
punch, blade, electrosurgical unit, hemostatic agents, suture
material, basic surgical pack, and gauze should be available.
For actinic keratosis, preoperative topical treatment with
5% 5-fluorouracil (5-FU) and/or retinoids reveals the affected
areas and reduces the size and number of lesions remaining
to be treated with cryosurgery, and may make the lesions
more responsive to treatment by reducing the keratin layer.
Debulking the lesion is useful for thick and elevated lesions.
Reducing a thick tumor by shaving or curettage, although
ideal, might not always be possible or recommended, espe-
cially when treating patients with coagulopathies, blood-
borne diseases, highly vascularized tumors, or those taking
anticoagulant medication.

157
Chapter 10  Cryosurgery
Table 10.2  Diseases that can be treated with cryosurgery14
DURATION (SECONDS)
TEMPERATURE (°C)
Benign lesions
Warts15,16
Condilomata accuminata
10
−196
Molluscum contagiosum
10–20
−196
Larva migrans17,18
20–30
−86
Leishmaniasis19,20
30
−86/−196
Chromomycosis21
Double cycle (spray)
−196
Seborrheic keratosis
10–20
−196
Benign pigmentary lesions: lentigines, lentigo simplex, solar lentigo, ephelides
5–20
−86/−196
Cystic acne, rosacea
5–10
−86/−196
Hypertrophic lichen planus, lichen sclerosus et atrophicus22
20–30
−86/−196
Athrophic scars
cryopeeling
Keloids
30
−86/−196
Prurigo nodularis
20–30
−86
Dermatofibroma23
30
−86/−196
Chondrodermatitis nodularis helicis chronica
20–30
Mucocele, myxoid cyst24
10–20
−196
Alopecia areata25
10
−86
Sebaceous hyperplasia, steatocystoma multiplex, syringomas, xanthelasma
20–30
−86
Granuloma annulare26
10–20
−86
Granuloma faciale
10–20
−196
Chronic discoid lupus erythematosus
20–30
−86
Lymphocytoma cutis
20–30
−86
Trigeminal neuralgia
20–30
−196
Pearly penile papules
10
−196
Vascular lesions
Hemangiomas
10–20
−86/−196
Venous lake
10–20
−86/−196
Vascular malformations (like angiokeratoma)
30
−196
Pyogenic granuloma
20–30
−86/−196
Premalignant and malignant lesions27
Actinic cheilitis28
20–30
−196
Basal cell carcinomas29
2 × 30
−196
Bowen’s disease
2 × 30
−196
Kaposi’s sarcoma30
2 × 30
−196
Lentigo maligna31,32
2 × 30
−196
Squamous cell carcinomas
2 × 30
−196
Palliative treatment33,34
2–3 × 30
−196
HIV patients, special considerations should be taken before
treating anal condylomata. Previous biopsy to rule out squa-
mous cell carcinomas is important. Also, for lesions at the
anal margin, a rectoscopy detects lesions inside the anal canal
and avoids cryosurgical interventions in patients requiring
further surgical interventions.
Molluscum contagiosum
Both the open and closed techniques are used to treat mol-
luscum contagiosum. In the open technique, use a B or C tip,
and point the spray at the center of the lesion, avoiding pen-
dular or brush painting movements. The freezing front has to
spread just to the outside margin of the lesion.
For the probe technique, if the lesion is small, use a fine-
point probe, such as the eyelid probe, that has previously
been frozen to avoid it sticking to the surface. This method
is faster and allows the treatment of multiple lesions in one
session. No anesthesia is required.
Cutaneous larva migrans
Although cryosurgery is not the first choice for treatment, it
can work well for resistant cases or when oral medication is

158
Part 2  Essential Surgical Skills
gery. Do not treat melasma with cryosurgery because there
is a tendency for residual hyperpigmentation. With superficial
freezing, the lesion is eliminated by sloughing of the separated
superficial skin. Therefore, the risk of hypopigmentation
rarely exists. If it occurs, it is because there has been over-
treatment with melanocyte destruction.
Acne
Cryosurgery can be helpful for acne lesions, scars, and rosacea.
Cold has an initial inflammatory effect, but after 24–48
hours, pustules and cysts tend to disappear faster than
without any treatment. It is a good alternative during preg-
nancy, when systemic acne treatments are usually avoided.
Spray the whole area for approximately 5–7 seconds. There
is no need to freeze beyond the outer limit of the lesion. The
treated area may be drained later and will need to be covered
with antibiotic ointment. In order to avoid insufflation of
nitrogen and local crepitation similar to that seen in gangre-
nous areas, spraying should never be done over incised and
drained lesions.
In rhinophyma, good cosmetic results can be obtained by
removing the excess rhinophyma tissue with electrodesicca-
tion. Then a C tip intermittent cryospray is applied to the
base. Avoid overtreatment. It is better to undertreat and
repeat a cryosurgical session than to risk destroying under­
lying tissue by excess treatment.
Hypertrophic scars and keloids
Several studies during recent years have shown that cryosur-
gery, either as monotherapy or in combination with other
treatment, is an effective and safe therapeutic regimen in
hypertrophic scars and keloids35 (Table 10.3) (Fig. 10.5).
Cryosurgery as monotherapy was first used by Shepherd
and Dawber in 1982 to treat 17 patients with keloids with a
single cryosurgical session. They achieved 80% improvement
of the lesions; however, they observed a high recurrence
rate of 33%.43 With the exception of case reports, further
studies were delayed by this rather disappointing recurrence
rate. Mende36 as well as Zouboulis and Orfanos44 showed
that repeated cryosurgical sessions can exhibit a beneficial
effect on keloids and hypertrophic scars and additionally
prevent relapses. In 72 of 89 (81%) patients with hyper-
not tolerated or available. A previously frozen 3-mm cryo-
probe is applied at both ends of the trail and freezing is
carried out for 5–7 seconds.
Seborrheic keratosis
Cryosurgery is probably the fastest, safest, and cheapest way
to treat seborrheic keratosis. Treat only when diagnosis is
confirmed by clinical or dermatoscopic evaluation. Many
lesions can be treated in a single session (Fig. 10.4). Use the
cryospray in an intermittent manner with a B or C tip until
the freeze halo covers the whole lesion surface and extends
to a maximum of 1 or 2 mm. After thawing for a few seconds,
until part of the white freeze halo has disappeared, curettage
the frozen lesion with one or two curette strokes. Since freez-
ing is followed by an immediate vasodilator effect, be ready
to apply a hemostatic substance with a cotton swab dipped
in aluminum chloride. Curettage of the frozen lesion will
speed up recovery, but is not mandatory. For a very large
seborrheic keratosis, apply local anesthesia. With practice, a
large number of seborrheic keratoses can be removed in a
single session with extremely satisfying results.
Solar lentigo
Pigmented lesions, such as lentigines, lentigo simplex, and
ephelides, are very susceptible to cold. Most of them are
superficial and a single freezing cycle carried out with the
spray technique is sufficient to cause a small bulla and sub-
sequent sloughing. The diagnosis has to be confirmed by
dermatoscopy prior to treatment. If in doubt, biopsy is man-
datory. Never freeze a pigmented lesion without knowing the
diagnosis.
Solar lentigo, ephelides, and lentigo simplex can be treated
individually with a B or C tip pointed perpendicularly over
the pigmented lesion, with intermittent spraying for no more
than 3–5 seconds on each one, at a distance of approximately
2 cm. Allow the freeze halo to advance barely outside the
outer edge of the macule. If the freezing leaves an untreated
outer rim, the result may be disappointing, with a residual
pigmented ring around the treated area.
For Fitzpatrick skin type III, it is best to treat one or two
lesions in less noticeable areas and check for the final appear-
ance. Sometimes darker skin can hyperpigment with cryosur-
Figure 10.4  Single one-
cycle spray treatment of a
large seborrheic keratosis.

159
Chapter 10  Cryosurgery
the size and the location of lesions, and pretreatment with
another method did not influence the outcome of cryosurgi-
cal treatments.37 Cryosurgery exhibited significantly better
results than intralesional triamcinolone (5  mg/lesion) in a
randomized study with 11 patients with multiple acne keloids,
especially in early, vascular lesions.46
Cryosurgery was initially applied in the treatment of hyper-
trophic scars and keloids as a weekly cryotherapy regimen
prior to intralesional corticosteroids in order to induce tissue
edema and to facilitate intralesional injections. This combina-
tion regimen of Hirshowitz et al.41 demonstrated significant
regression of keloids in 119 of 159 patients (75%).39–42 The
combined therapy with intralesional corticosteroids was
trophic scars and 241 of 356 (68%) patients with keloids,
there was greater than 50% improvement or complete regres-
sion after cryosurgery.36–40
Acne keloids showed 73% improvement or complete
regression in 16 patients treated.45 Early lesions (<2 years old)
respond better than older ones. Progression or recurrence was
rare (2%) in this study. In order to achieve these results,
anything from one to more than 20 sessions with an average
of 30 seconds of cryogen applied monthly using the contact
method of treatment were required. The number of sessions
and age of lesions correlated significantly with the treatment
result: more than three sessions and lesions less than 2 years
old had the best results. The age and the sex of the patient,
Table 10.3  Cryosurgery of keloids and hypertrophic scars: clinical results
STUDY
TOTAL NUMBER
OF PATIENTS
Significant to complete
remission
Recurrences
NUMBER
%
NUMBER
%
Cryosurgery as monotherapy
Keloids
Mende36
7
5
71
–
Zouboulis et al37
55
28
51
–
Rusciani et al38
40
34
85
–
Ernst & Hundeiker39
234
158
68
9
4
Zouridaki et al40
20
16
80
–
Total
356
241
68%
9
3%
Hypertrophic scars
Zouboulis et al37
38
29
76
–
Ernst & Hundeiker39
51
43
84
2
4
Total
89
72
81%
2
2%
Cryosurgery combined with intralesional corticosteroids
Keloids
Hirshowitz et al41
58
41
71
9
16
Ernst & Hundeiker39
56
38
68
2
4
Zouridaki et al40
20
19
95
–
Banfalvi et al42
25
21
84
–
Total
159
119
75%
11
7%
Figure 10.5  Cryosurgery of
a keloid after save-excision
into the borders of the initial
lesion.

160
Part 2  Essential Surgical Skills
hemangioma. Deep hemangiomas should not be treated with
cryosurgery.
Pyogenic granulomas
Pyogenic granulomas can be treated with the closed tech-
nique (like a hemangioma) or with the spray technique (in
large tumors), letting the freezing front advance slowly to the
base of the tumor and later shaving and freezing the base with
a probe (Fig. 10.6).
Vascular malformations
Cryosurgery can be a great help in the treatment of certain
vascular malformations. Capillary (port-wine stain) vascular
malformations tend to become thicker over the years and
respond less to dye laser treatment. By reducing the thickness
of the lesion, the general appearance improves and it is easier
to camouflage with make-up. Bulky nodules can be treated
by grasping the protruding portion with a previously frozen
forcep until the freezing front reaches the base. The hyper-
trophic area responds well to freezing with the door knob
probe (developed by Torre and Garamy at Frigitronics; avail-
able through Brymill Cryogenic Systems). This probe, which
is a teflonized door knob, is previously frozen and applied
with pressure, moving across the area like ‘ironing’ the
surface. It is a well-tolerated procedure. The end result is a
clearer and thinner area with extremely satisfying results.
Venous lakes55 are very common and can easily be treated
using a previously frozen probe of the same size of the lesion,
applied with pressure (to empty the content) for 4–5 seconds
(Fig. 10.7).
Lymphangiomas
Lymphangiomas tend to be the clinical expression of larger
underlying tumors. Probes applied to each individual lesion
allow selective destruction with good cosmetic results. Pres-
sure should be applied to each lesion to empty the contents.
For multiple small lesions, no local anesthesia is necessary.
Treat with previously frozen small-diameter probes for 5–7
seconds or until the freezing front has reached 1–2  mm
outside the outer margin of the lesion.
found superior to cryosurgery alone in one randomized (n =
10)47 and one open (n = 145)48 study, or at least equally
effective (one randomized study, n = 40).46 Interestingly the
progression rate of 7% is markedly higher than the one of
cryosurgery alone (2%).
Lesions refractory to cryosurgery or cryosurgery combined
with intralesional corticosteroids can be surgically removed.
In large keloids, postsurgical cryoprevention with or without
intralesional corticosteroids can be performed in order to
reduce recurrence.49 Intramarginal excision is advisable
because it is followed by a lower recurrence rate when com-
pared to extramarginal excision. Removal of the lesion by
surgery or carbon dioxide laser has similar recurrence rates;
however, the carbon dioxide laser provides a high degree of
hemostasis and avoids suture scarring.
In order to improve the efficacy of the regimen and reduce
the number of sessions required, Zouboulis and Orfanos50
modified the method of intralesional cryosurgery introduced
by Weshahy.11 Har-Shai et al. achieved a 51% volume reduc-
tion after a single treatment in 10 patients.51 Two further
pilot studies presented contradictory results with 20% vs 83%
flattening of lesions in 10 and 12 patients, respectively.52,53
Further evidence on the efficacy of this interesting technique
is required.
Hemangiomas
Vascular tissue is extremely susceptible to cold. Hemangi-
omas appear during the first week of life, grow fast, and
involute slowly. Controversy exists on whether hemangi-
omas should be treated. If treatment is to be carried out, a
capillary hemangioma is ideally treated as soon as it appears.54
The treatment should be done by contact technique with
a probe fitted over the whole lesion. In superficial lesions,
a single application with a previously frozen probe applied
with pressure (to empty the lesion of blood) for 10–20
seconds is often sufficient. Allow the freeze halo to advance
just 1 or 2 mm from the outer limit of the lesion. For heman-
giomas with both superficial and deep components, com­
bination treatment is necessary. Freeze the superficial part
with a previously frozen probe applied with pressure.
Use intralesional corticosteroids in the deep part of the
Figure 10.6  Single one-cycle
spray treatment of a giant
pyogenic granuloma at the
right jawline.

161
Chapter 10  Cryosurgery
to spread a few millimeters beyond the margin. For thicker
lesions, longer freezing (10–15 seconds) is used.
Actinic keratoses are usually present in sun-damaged areas,
thus the concept of ‘field cancerization’ is important. Clearing
the sun-damaged area not only of the clinically evident actinic
keratoses but also of preneoplastic cells at the periphery of
the visible lesion will result in more radical treatment with
better oncologic and cosmetic results. Pretreatment of sun-
damaged areas with 5-FU, retinoids, salicylic, or glycolic acid
formulations clears most of the damaged skin as well as
reducing the size of the hypertrophic lesions. The exfoliation
and lesion size reduction allows better cold penetrance. 5-FU
removes many preneoplastic and neoplastic cells by inducing
apoptosis. Combination treatment of 5-FU and cryosurgery
has showen better actinic keratosis clearing than monotherapy
(Fig. 10.8). Chiarello56 has shown excellent results with
partial- and full-face cryopeeling.
Basal cell carcinoma
Basal cell carcinoma can be treated with the open, closed, or
chamber technique (Fig. 10.9). A careful dermatoscopic
and dermatopathological evaluation allows confirmation of
the type of basal cell carcinoma. For superficial basal cell
carcinoma, the open technique is the most suitable. Spray
intermittently, pointing at the center of the lesion, and allow
the freeze halo to advance 5 mm outside the margin of the
lesion. The time will be determined by the size, but it can
take more than 60 seconds. It is ideal for treating multiple
Mixed malformations (venous–capillary–arterial)
For patients with possible mixed malformations, imaging
studies such as nuclear magnetic angiogram with contrast
enhancement, selective arteriography, echosonography, and
computed tomography are performed before treatment to
determine the extent of the lesion and vessel diameter.
A multidisciplinary team of head and neck, cardiovascular,
plastic, and dermatologic cryosurgeons, together with inter-
ventional radiologists, is needed to provide the expertise to
treat such lesions. Many hospitals are forming teams to help
treat lesions that were previously considered untreatable.
Large vascular tumors fed by big arteries or veins will
require embolization or ligation to reduce or even eliminate
blood flow to the lesion. In the same surgical procedure or in
a second attempt, cryosurgery of the residual vascular mass
can be used to destroy the remaining tumor. In general, it is
extremely difficult to determine freezing time for vascular
tumors because many factors are involved, such as lesion
volume, probe size, and collateral vascularization. They tend
to be undertreated and numerous procedures are necessary
to eliminate or reduce these tumors.
Actinic keratosis
Cryosurgery is a widely used method for the treatment of
actinic keratosis. It can work well for isolated or multiple, flat
or keratotic lesions. In the presence of few lesions, cryosur-
gery is applied for 5–10 seconds, allowing the freezing front
Figure 10.7  Venous lake
before and after a single
treatment with a 3-mm
previously frozen probe.
Figure 10.8  Combination
palliative treatment (5% 5-FU
plus two-spray cryosurgery
cycles) in a bed-ridden
patient.

162
Part 2  Essential Surgical Skills
dates for cryosurgery. It is important to carefully select
patients for this treatment option (Fig. 10.10).57 For squa-
mous tumors, a 1-cm spread beyond the tumor margin and
two freezing cycles should be carried out. The chamber tech-
nique is another option to spray and probe.
Kaposi’s sarcoma
Kaposi’s sarcoma can be a bothersome aesthetic problem
when on the face. Since vascular lesions are extremely sensi-
tive to cold, cryosurgery is an excellent treatment. When
Kaposi’s sarcoma is persistent and visible in spite of previous
antineoplastic or antiretroviral treatment, cryosurgery becomes
the therapeutic choice, with results varying from complete
disappearance of the lesion to a faded, less violet and more
acceptable appearance. Both open and closed technique can
lesions. Nodular lesions can be treated with the open, probe,
or chamber technique. Before treatment, clean locally with
antiseptic solution, apply local anesthesia and, when neces-
sary, curette the excess tissue and apply a hemostatic agent.
For contact freezing, choose a probe that fits best or one
smaller than the diameter of the lesion. Apply the probe per-
pendicular to the skin; begin to freeze in an intermittent
manner until the tip adheres to the surface, and continue
freezing until a 4–5-mm rim appears outside the lesion margin.
For solid basal cell carcinomas, two cycles are recommended.
Squamous cell carcinomas
In-situ squamous cell carcinoma lesions have shown excellent
response to cryosurgery. Well-localized and well-differenti-
ated tumors not affecting local lymph nodes are good candi-
Figure 10.9  Single-probe
cycle in basal cell carcinoma
of the cheek.
Figure 10.10  Cutaneous
horn with squamous cell
carcinoma in situ in the
eyelid treated with shaving
and two-probe cycle.

163
Chapter 10  Cryosurgery
Therefore, fractional or segmental cryosurgery are options for
the management of large tumors. Fractional cryosurgery59
consists of reducing the size by treating the center of the
lesion first, allowing it to heal, and then later treating the
remaining area, which is now smaller than the original (Fig.
10.11). After one or more treatments, the original tumor will
be reduced to a more manageable size. Segmental cryosurgery
(Fig. 10.12) consists of dividing the tumor in an imaginary
grid and treating one area at a time either at the same time
or in different sessions. Combination treatments with cyto­
static drugs (cryochemotherapy) is showing promising
results.60,61
 POSTOPERATIVE CARE
Postoperative care in cryosurgery is extremely important and
has a long duration. Patients should know about the anti­
cipated healing time, expected secondary effects, and prob-
able complications. Verbal and written instructions are
helpful. Regular follow ups are advisable to control outcome.
The physical course of the cryoreaction and related secondary
effects are as follows:
be used. For spraying, double freeze–thaw cycles are employed.
One single probe application allows the freezing front to
advance just a few millimeters outside the vascular lesion.
Lentigo maligna
Cryosurgery in lentigo maligna is an option based on the
melanocytes’ high sensitivity to low temperature. Only Mohs
surgery has shown better results than cryosurgery for lentigo
maligna. In large lesions and lesions in older and inoperable
patients, cryosurgery is the best option. It should be treated
with a double freeze–thaw cycle with a 1-cm margin. Com-
bination with immunomodulators seems to be a promising
treatment for this condition.32
Palliative treatment
Palliation with cryosurgery is an exciting and growing field. It
has provided a treatment option for numerous patients who
are unable to have other surgical and medical treatment. It is
considered in the following circumstances:
• When the skin tumor does not respond to conventional
treatment (chemotherapy, radiotherapy, or surgical
treatment).
• When the secondary effects of the usual treatments are
no longer tolerated by the patient.
• When underlying medical conditions (such as anemia,
coagulopathies, heart conditions, diabetes mellitus, and
old age) increase the risks of conventional treatments.
• When the proposed surgical procedure to reduce or
remove the tumor is so disfiguring that the patient
rejects it.
• In metastasis of skin tumors or internal tumors.
Palliative cryosurgery is used to relieve symptoms. Some of
these tumors can be so destructive and deforming that they
cause easy bleeding, local infection, and subsequent foul smell
and pain. Cryosurgery reduces all of these symptoms, thus
improving quality of life. Because the tumors to be treated
tend to be big, solid, protuberant, and bleed easily, the most
frequently used technique is the open cryospray. Attempting
to shave them (by curettage or electrodesiccation) to reduce
their original size, although possible and ideal,58 is not always
advisable because these tumors have an enormous network of
neovascularization. The patients tend to be anemic.
For certain individual tumors, the chamber technique is
ideal for thick tumors. The chamber has to fit precisely over
the tumor. Chamber turbulence allows extremely cold tem-
peratures, which are ideal for highly resistant tumors. They
also keep the cold within a well-defined area. It is very impor-
tant to apply pressure when using chambers to avoid leakage
of liquid nitrogen to the sides of the lesion. For enormous
tumors, cryospray works well. It is important to apply it with
the spray fixed at one point and allow cold to spread to the
periphery. Avoid brushing the spray from one side to the
other because this gives the false impression of having
obtained the desired low temperatures.
Overtreatment of these lesions is very rare. There is a
tendency to undertreat them and sessions have to be repeated
every 2 weeks until the tumor is sufficiently destroyed to
reduce bleeding and pain.
Large tumors cannot be frozen from the center to the
periphery simply by allowing the freezing front to advance
because the destruction at the center would be too deep.
Advancing
freezing point
Central necrosis
Central scar
Final tumor size
(smaller than original)
Central tumor
elimination
Original tumor size
Central scarring
Partial central
freezing
Fractional cryosurgery
Figure 10.11  Fractional cryosurgery.
Tumor-free area after
healing (central scar)
The ice ball
Segmental cryosurgery
Figure 10.12  Segmental cryosurgery. Tumor divided into four
segments. The upper outer segment is treated, leaving a
tumor-free area (gold) with a central scar.

164
Part 2  Essential Surgical Skills
Oral anti-inflammatory drugs are of little use and systemic
antibiotics should only be used if infection is clinically con-
firmed. Bacterial infection occurs rarely but is possible when
deep freezing has been carried out and proper cleaning pro-
cedures were not followed. The reappearance of local pain
several days or weeks after cryosurgery may suggest second-
ary bacterial infection.
 PITFALLS AND THEIR MANAGEMENT
1. Erythema can be immediate or appear up to 30 minutes
after cryosurgery.
2. Discomfort or even pain. An immediate local burning
sensation occurs at the end of freezing time and during
thawing. It is usually well tolerated. Pain can occur and
will depend on cold tolerance and freezing depth. When
pain is expected, local topical or injected anesthesia can
be used and prior oral analgesics may be indicated.
3. Edema occurs from a few minutes to hours after
treatment. The duration depends on the freezing depth
and also on the skin type, being more important in type
I and II skin. It can range from hours after treatment in
superficially treated lesions, to 3–5 days in deep
freezing. It is not related to pain. It is probably the
effect causing most anguish if not previously explained.
Warning to patients will reduce anxiety and alarmed
phone calls. In areas close to orifices (e.g. nostrils,
mouth, and eyelids), the edema can be bothersome.
4. Bulla formation is usually present between 1 and 3 days
after treatment. It can contain a bloody exudate,
especially if prior curettage was performed. It usually
breaks spontaneously or can be removed to hasten
healing. In order to avoid bleeding episodes, do not
remove the bulla when the lesion was a vascular tumor
or a keloid.
5. Exudation can last from a few days to 10–15 days after
cryosurgery. It is more abundant during the first few
days and reduces by itself over time. If there is a large
amount of exudate, frequent daily dressing changes are
indicated.
6. Mummification with crust formation occurs after the
exudate is minimal. Scab removal can be helpful to
speed healing; however, do not remove a crust on
vascular lesions or keloids. To avoid secondary infection,
topical antibiotic ointments should be used as the lesion
gets drier.
7. Healing will last longer for deeper freezing. Hydrocolloid
dressings can help reduce healing time. For superficially
sprayed lesions on the face, one could expect 1 week of
postoperative time before complete healing occurs. For
probe cryosurgery, the deeper the freezing time or the
greater the number of cycles, the longer the time it will
take to heal. Healing of a probe-treated area on the face
can take 3–4 weeks. For a lesion of the same size and
treated with the same technique, on the legs, healing
can be as long as 2–3 months.
8. Postoperative redness and hypopigmentation. Right after
healing, the treated area can look erythematous for a
variable amount of time. This redness can last weeks
and the patient should be strongly advised to use sun
protection to avoid hyperpigmentation. Once the
redness has disappeared, a hypopigmented area may
remain. If freezing was superficial, as in the case of
benign lesions, this hypopigmentation will last just a few
weeks and then improve until normal pigmentation is
re-established. In deep freezing, such as for skin cancer
or hemangiomas, this hypopigmentation tends to last
years. In some patients, hypopigmentation can be
permanent.
9. Pseudoepitheliomatous hyperplasia is a secondary effect
that can be expected with deep freezing. It does not
require treatment and disappears spontaneously after a
few months.
Pitfalls and their management
Expected occurrences
Edema and swelling
Vesicle or bulla formation
Exudation
Tissue sloughing
Eschar formation
Hypopigmentation (in deep cryosurgery)
Occasional temporary cryosurgical events
Secondary infection
Inadvertent burn
Milia
Occasional permanent cryosurgical events
Permanent hypopigmentation or achromia
Retraction
Notching of ear or ala of nose
Alopecia
Nail dystrophy
Atrophic or depressed scar
As with every method, pitfalls can occur. In cryosurgery,
postoperative sequelae may be temporary or occasionally per-
manent. Most pitfalls attributed to cryosurgery are the result
of inappropriate technique. Therefore, correct training will
reduce many unwanted secondary effects. The equipment is
readily available and the apparent simplicity of the method
has facilitated indiscriminate use without following proper
patient selection. Temporary complications include:
• Bleeding: possible in deep freezing once the necrosis
of the tissue sets in and small vessels become exposed.
It can be controlled by hemostatic solution but
occasionally requires electrocoagulation or even ligation
of the vessel with a suture.
• Headache: if the treated area was in the scalp or face.
• Infection: can be recognized by the presence of pus,
excessive redness, and pain that appear days after the
treatment.
• Nitrogen gas insufflation: can occur if the open
technique is used on a previously drained cyst.
• Hypertrophic scarring, cold urticaria, or paresthesia:
these have also been described.
• Hyperpigmentation.
• Milia formation at the site of bulla formation.
Occasional permanent complications include:
• Retraction of tissue, when cryosurgery has been
performed near the lips, ala nasi or eyebrows.
• Alopecia.
• Ectropion.

165
Chapter 10  Cryosurgery
19. Al-Gindan Y, Kubba R, Omer AH, et al. Cryosurgery in old world cutane-
ous leishmaniasis. Br J Dermatol 1988;118:851–854.
20. Faber WR. Cryosurgery for cutaneous leishmaniasis. J Dermatol Surg
Oncol 1983;9:354–356.
21. Castro LG, Pimentel ER, Lacaz CS. Treatment of chromomycosis by
cryosurgery with liquid nitrogen: 15 years’ experience. Int J Dermatol
2003;42:408–412.
22. August PJ, Milward TM. Cryosurgery in the treatment of lichen sclerosus
et atrophicus of the vulva. Br J Dermatol 1980;103:667–670.
23. Hill AC, Dougherty JW, Torre D. Cryosurgical treatment of dermatofi-
bromas. Cutis 1975;16:517–518.
24. Kuflik EG. Specific indications for cryosurgery of the nail unit. Myxoid
cysts and periungual verrucae. J Dermatol Surg Oncol 1992;18:702–
706.
25. Mullins EA. Cryosurgical therapy of alopecia areata. In: Dyall-Smith D,
Marks R, eds. Dermatology at the millennium. New York: Parthenon
Publishing Group 1999; 550–551.
26. Blume-Peytavi U, Zouboulis CC, Jacobi H, et al. Successful outcome
of cryosurgery in patients with granuloma annulare. Br J Dermatol
1994;130:494–497.
27. Kuflik EG. Cryosurgery for cutaneous malignancies. An update. Derma-
tol Surg 1997;23:1081–1087.
28. Dufresne RG, Curlin MU. Actinic cheilitis. A treatment review. Derma-
tol Surg 1997;23:490–491.
29. Mallon E, Dawber R. Cryosurgery in the treatment of basal cell carci-
noma. Assessment of one and two freeze–thaw cycle schedules. Dermatol
Surg 1996;22:854–858.
30. Tappero JW, Berger TG, Kaplan LD, et al. Cryotherapy for cutaneous
Kaposi’s sarcoma (KS) associated with acquired immune deficiency syn-
drome (AIDS): a phase II trial. J Acquir Defic Syndr 1991;4:839–846.
31. Kuflik EG, Gage AA. Cryosurgery for lentigo maligna. J Am Acad
Dermatol 1994;31;75–78.
32. Bassukas ID, Gamvroulia C, Zioga A, et al. Cryosurgery during topical
imiquimod: a successful combination modality for lentigo maligna. Int J
Dermatol 2008;47:519–521.
33. Kuflik EG. Cryosurgery for palliation. J Dermatol Surg Oncol
1985;11;867–869.
34. Pasquali P. Cryosurgical palliation for advanced malignancies. In: Dyall-
Smith D, Marks R, eds. Dermatology at the millennium. New York:
Parthenon Publishing Group 1999; 564–565.
35. Zouboulis CC, Zouridaki E, Rosenberger A, et al. Current developments
and uses of cryosurgery in the treatment of keloids and hypertrophic
scars. Wound Repair Regen 2002;10:98–102.
36. Mende
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37. Zouboulis CC, Blume U, Büttner P, et al. Outcomes of cryosurgery in
keloids and hypertrophic scars. A prospective consecutive trial of case
series. Arch Dermatol 1993;129:1146–1151.
38. Rusciani L, Rossi G, Bono R. Use of cryotherapy in the treatment of
keloids. J Dermatol Surg Oncol 1993;19:529–534.
39. Ernst K, Hundeiker M. Ergebnisse der Kryochirurgie bei 394 Patienten
mit hypertrophen Narben und Keloiden. Hautarzt 1995;46:462–466.
40. Zouridaki E, Trautmann C, Alvertis H, et al. Cryosurgery alone and
cryosurgery combined with intralesional steroids are equally effective on
keloids but induce different histological changes: results of a prospective
randomised study. J Eur Acad Dermatol Venereol 1996;7(Suppl 2):87.
41. Hirshowitz B, Lerner D, Moscona AR. Treatment of keloid scars by
combined cryosurgery and intralesional corticosteroids. Aesth Plast Surg
1982;6:153–158.
42. Banfalvi T, Boer A, Remenar E, et al. Treatment of keloids (review of
the literature, therapeutic suggestions). Orv Hetil 1996;137:1861–1864.
43. Shepherd JP, Dawber RPR. The response of keloid scars to cryosurgery.
Plast Reconstr Surg 1982;70:677–681.
44. Zouboulis CC, Orfanos CE. Kryochirurgische Behandlung von hypertro-
phen Narben und Keloiden. Hautarzt 1990;41:683–688.
45. Röhrs H, Orfanos CE, Zouboulis CC. Cryosurgical treatment of acne
keloids. J Invest Dermatol 1997;108:396.
46. Layton AM, Yip J, Cunliffe WJ. A comparison of intralesional triamcin­
olone and cryosurgery in the treatment of acne keloids. Br J Dermatol
1994;130:498–501.
47. Yosipovitch G, Widijanti Sugeng M, Goon A, et al. A comparison of the
combined effect of cryotherapy and corticosteroid injections versus
corticosteroids and cryotherapy alone on keloids: a controlled study.
J Dermatolog Treat 2001;12:87–90.
48. Jaros E, Priborsky J, Klein L. Treatment of keloids and hypertrophic scars
with cryotherapy. Acta Medica (Hradec Kralove) 1999;42(Suppl):
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49. Zouboulis CC, Blume U, Orfanos CE. Keloids and hypertrophic scars:
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Monatsschr 1993;179:278–284.
• Permanent hypopigmentation.
• Others: tendon rupture, ulceration, tissue defect.
 SUMMARY
Cryosurgery is an extremely versatile method that has become
indispensable in a dermatologist’s office. It is the first treat-
ment option for many common skin conditions and a valid
alternative for the treatment of many others due to its low
cost and time-saving advantages. Under certain circum-
stances, such as advanced age and underlying comorbid dis-
eases, cryosurgery becomes the sole option for treatment.
Palliative treatments with cryosurgery offer a whole array of
possibilities in a field of medicine where many options are no
longer possible.
Combination treatment with other surgical or topical treat-
ments with the diagnostic help of image technology will
further broaden the spectrum of application of this already
versatile method.
 REFERENCES
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167
11
Skin Biopsy Techniques
Andrew G Affleck BSc(Hons) MBChB MRCP(UK) and Graham Colver DM FRCP FRCPE
Summary box
 The skin biopsy is essential to dermatologic surgery both in
diagnosis and planning therapy.
 Several biopsy techniques are available, including shave,
saucerization, curettage, scissors ‘snip,’ punch, and scalpel
excision or incisional biopsy.
 Complications are infrequent but can be minimized by careful
preoperative evaluation for risk factors and by meticulous
technique.
 The biopsy site should be selected carefully taking into
account the aesthetic consequences and the planned
therapy.
 The choice of technique depends on the type of lesion, (e.g.
benign vs malignant), size, site, and the objective of the
biopsy (e.g. excise the entire specimen to obtain the total
process or incise to sample a small part of the process for
pathology).
 INTRODUCTION1,2
Definition
Skin biopsy can be defined as the removal of a piece of skin
for the purpose of further examination in the laboratory –
normally using a microscope. It is an essential part of the
dermatologist’s diagnostic repertoire. The term excisional
biopsy is usually reserved for the process of removing, in its
entirety, a solitary skin lesion. Incisional biopsy refers to the
removal of part of a lesion or dermatological condition. Terms
such as punch, shave, and curette biopsy define more accu-
rately the precise method used.
Uses
Biopsy material is processed and studied by a histopathologist
with a view to making a diagnosis or ruling out certain pos-
sibilities. To some extent this depends on the proficiency of
the histopathologist – for instance, it may be possible to
exclude a malignant lesion without necessarily being able to
identify the exact nature of an appendageal tumor. Equally it
may be obvious that a scaly dermatitis shows no pathological
features of lupus erythematosus yet no other specific features
are seen. Biopsies can also be used to monitor the progress
of a disease through its natural history or in its response to
therapy (Box 11.1).
Best and worst sites
Certain body sites are likely to heal quickly and leave reason-
able scars whereas other sites are prone to delayed healing,
infection, and unacceptable scars. In addition there are path-
ological changes due to gravitational effects seen in depend-
ent areas, for example the lower legs, which can cloud the
histological picture. It may not be possible to choose a good
site for biopsy if the disease process is limited to a poor
healing area; however, if there is a choice, the physician will
try to avoid taking skin from below the knee and generally
the upper body is better than the lower body. Some general
principles are that:
• Infection is more common below the knee.
• Scars on the back often stretch.
• The ventral forearm often has a poor result.
• The dorsum of the hand heals well.
• The central face should be avoided if possible.
 TECHNICAL ASPECTS
Understanding the biology
Dermatologists are ideally placed to take skin biopsies because
they have the requisite training to make decisions about the
appropriate type of biopsy. This does not mean that they
will always make the best decision and there will be rare
occasions that, for instance, the shave biopsy of a suspected
seborrheic keratosis is reported as a thick melanoma. But it
is dermatologists’ understanding of the biology of skin disease
that enables them to make the right decision most of the
time.
Some important general principles follow:
• Recent lesions from a skin eruption are more likely to
show diagnostic features than are older resolving lesions.
It is best to avoid excoriated or secondarily infected
lesions.
• Pathologists prefer material from the edge of a plaque
or annular lesion.
• Distinguish between keratin and crust. Crust should be
removed gently by irrigation prior to biopsy
(Figs 11.1 and 11.2).

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Part 2  Essential Surgical Skills
taken. Although punch biopsy can be performed, it is
generally better to take a wide incisional elliptical piece
of tissue. In some cases of panniculitis, this may need to
be over 2 cm deep.
• The edge of an ulcerated lesion may show
pseudoepitheliomatous changes. It is best to include
some normal skin and to avoid small specimens.
• In areas with multiple actinic lesions, it is easy to ‘lose’
the biopsy site a week later when the pathology is
reported. This is awkward if further treatment is
needed. Marking the biopsy site with a suture, even
after a curette biopsy, helps to avoid this difficulty
(Fig. 11.3).
Processing and the request form
Pathologists and clinicians work in partnership; one cannot
do well without the other and this interdependence is seen
in many ways. The clinician’s duty is to provide an appropri-
ate biopsy, sent in the correct transport medium and with
enough clinical detail written on the request form, to allow
pathologists to understand what is being asked of them. All
biopsy specimens must be carefully labeled, including the
names of the patient and physician and the date. The precise
site of the biopsy should be stated. A likely clinical diagnosis
should be given or a differential diagnosis listed. Specific
questions may be asked to allow the pathologist to choose
from a range of tinctorial stains,5 for example: ‘Are there
increased numbers of mast cells?’, ‘Is there any excess
mucin?’, ‘Any evidence of fungal elements?’
Care should be taken when handling the tissue to allow for
the most accurate interpretation of changes. If three or four
studies are to be performed on the tissue, it is often best to
take more than one specimen, rather than divide one speci-
men into three small pieces, to avoid crush artifact.
Formalin
Most diagnostic microscopy is performed on paraffin-
embedded material, and 10% neutral buffered formalin is the
usual fixative. It is helpful to visit the pathology department
and watch the technicians cutting and embedding tissues,
maintaining the correct orientation until the wax begins to
set. It becomes more clear why tiny punch biopsies may often
result in a report which comments on poor orientation and
subsequent cross-sectioning.
• Shave excision or curettage is often appropriate for
epidermal lesions but a deeper biopsy may give useful
additional information, for example the thickness of a
basal cell carcinoma, which may influence further
treatment.
• Biopsies of dermal lesions should take deeper tissue, for
example incisional elliptical excisional or punch biopsy.
• Pathology in the subcutaneous tissue can only be
assessed if biopsies to the depth of the deep fat are
Figure 11.1  Crusted lesion on the right temporal scalp.
Figure 11.2  Crust removed to reveal the extent of the ulcerated
tumor.
Figure 11.3  Marking the site of biopsy with a suture.
Box 11.1  Uses of a skin biopsy
 Achieve precise diagnosis.
 Exclude specific diagnoses.
 Provide histologic support for a clinical diagnosis.
 Monitor evolution of disease.
 Determine extent of a tumor (‘scouting’ biopsies).3
 Monitor response to treatment.
 Remove disfiguring tissue as a cosmetic procedure.
 Aid healing, e.g. punch excisions to fenestrate ear cartilage in
second intention healing.
 Diagnose non-cutaneous disease, e.g. genetic or connective
tissue disease, peripheral neuropathy.4

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Chapter 11  Skin Biopsy Techniques
Electron microscopy
This is little used in diagnostic dermatopathology although it
has greatly increased our knowledge about normal skin struc-
ture and certain pathological mechanisms. It can be used for
the diagnosis of some viral conditions and identification of
amyloid. The specimen is transported in glutaraldehyde.
 PREOPERATIVE EVALUATION,
CONSENT, AND ANESTHESIA
At times it may be tempting to take short cuts when perform-
ing a small procedure such as a punch biopsy. However, this
is a mistake because bleeding problems and the risks of
unsightly scars or infection are potential problems. If the
surgeon trivializes the situation, the patient is less likely to
be understanding about poor outcomes. Some issues are so
important that they bear repetition (see Chapters 3 and 5).
Evaluation before skin biopsy should be as thorough as
other skin surgical procedures (Table 11.1).7 It is essential to
ask about underlying medical diseases which may compro-
mise healing. Any relevant allergies should be noted and
current medications listed. Cautions for performing a skin
biopsy include severe coagulopathy, severe immunosuppres-
sion, and distal extremity in a diabetic patient or a patient
with severe peripheral vascular disease.
Traditionally, patients have been instructed to withhold
coumarin or aspirin therapy prior to skin surgery to minimize
bleeding complications. However, more recent evidence has
suggested that such agents do not alter outcome, and stopping
therapy may place the patient at unnecessary risk of a throm-
boembolic event.8 A prospective evaluation in 12 patients
undergoing Mohs surgery showed that although there was
increased intraoperative bleeding, this was easily controlled,
and only one patient (8%) needed to return for active inter-
vention.9 Another prospective study of 16 patients undergo-
ing cutaneous surgery showed that there were no significant
bleeding events in patients who continued to take warfarin
compared with 77 controls.10 The perioperative international
normalized ration (INR) level may be a poor predictor of
postoperative bleeding complications, emphasizing that
meticulous hemostasis is always imperative.11
Immunopathology
Whereas immunoperoxidase methods may be applied to
sections from paraffin-embedded tissue, the immunofluores-
cent (IMF) technique usually uses tissues which have been
snap frozen in liquid nitrogen, cut in a cryostat, and stained
without fixation. Other transport mediums, for example
normal saline or Michel’s medium,5 can be used depending
on local arrangements. It is usually a small, specific area, for
example the basement membrane, that is being studied and
so only small, specific biopsies are required. In the case of a
blistering disorder, it is common to take an ellipse through a
blister and to remove a 2–3 mm piece of the perilesional skin
for IMF.
Polymerase chain reaction (PCR)
This is used for the diagnosis of cutaneous lymphoma when
T-cell receptor gene rearrangement studies are performed.
Formalin-fixed or snap-frozen skin is used.
Cytology
Cytology is used widely in other disciplines such as cervical
diagnostics but is little used on primary skin lesions. Exfolia-
tive cytology and fine needle aspiration (FNA) offer advan-
tages such as time- and cost-effectiveness. It is also a
conservative means of arriving at a presurgical diagnosis of
basal cell carcinoma (BCC). This could be beneficial in situ-
ations where even a simple 2-mm punch biopsy may be
considered inappropriate, such as in a cosmetically sensitive
site in a young person or when non-surgical therapies are
planned. Normally a scalpel blade is used to scrape the surface
of the lesion; the material is then scraped onto a slide which
is fixed, stained, and immediately viewed under a micro-
scope. Bakis et al. performed a meta-analysis to ascertain the
diagnostic accuracy of exfoliative cytology for BCC.6 The
methodological quality was, in general, poor but a pooled
sample of 1261 BCCs showed the sensitivity to be high at 97%.
Only 3% of BCCs included were misdiagnosed as non-BCC
by cytology. The corresponding pooled specificity was 86%.
Exfoliative cytology is not recommended in the diagnosis
of cutaneous squamous cell carcinoma or melanoma but FNA
has an important role in biopsy of lymph nodes. Ultrasound-
guided FNA is performed by radiologists who can sample
pathological nodes in axillary, inguinal, and cervical regions.
However, if the enlarged lymph node is easily palpable, it can
be sampled without ultrasound using an 18-guage needle
attached to a 2-mL syringe containing 1 mL of normal saline.
Tiny core fragments obtained are expelled with the saline into
a universal container that is then spun down by the cytologist
before mounting and staining. This can give a quick result.
Cytodiagnosis is also used in the diagnosis of bullous dis­
orders and vesicular viral eruptions.
Culture
Fresh unfixed tissue may be cultured for various organisms,
including staphylococcus, mycobacterium, and fungi, or
examined for protozoa or filarial worms. Such specimens tend
to be placed in normal saline solution and transported to the
laboratory immediately. A special sealed vial is required for
anaerobic culture. Prior discussion with a microbiologist is
advisable so they know to expect the specimen.
Table 11.1  Preparing for biopsy checklist
Patient evaluation
Concomitant illnesses, e.g. bleeding
disorders, infection risk, pacemaker,
implantable defibrillator
Drugs, e.g. anticoagulants, antiplatelets
Allergies, e.g. wound dressings, lidocaine
Facilities
Clean, bright, spacious room
Suitable, sharp instruments
Adjustable examining table
Assistant
Consent
Include list of side effects and complications
Local anesthetic
Use least painful, e.g. without epinephrine if
possible
May not require any, e.g. some shave or
curette biopsies of BCC, scissor snip biopsy

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Part 2  Essential Surgical Skills
borne infections. The infection rate for minor cutaneous sur-
gical procedures is less than 1% and usually related to poor
surgical technique. Colonization with Staphylococcus aureus
is more common in patients with psoriasis, atopic dermatitis,
diabetes, intravenous drug users, or those taking isotretinoin
therapy.
Topical antimicrobial strategies include preoperative hand
washing and surgical scrubbing of the site. A good surgical
hand scrub is required only for sterile technique. It removes
debris, and transient and resident flora.
In spite of the above-mentioned facts, it is worth remem-
bering that skin cannot be truly sterilized. Approximately
90% of the flora resides in periungual areas and 20% in
adnexal structures. Even when using sterile gloves our tech-
nique may be clean and not sterile. Sterile gloves have a
1.5–3% failure rate, and this increases to 66% after 15 minutes
of use. Bacterial counts increase with moisture and there is a
30% incidence of unnoticed punctures during procedures.
Antibiotic prophylaxis
Biopsy of an ulcerated lesion, such as a tumor, pyoderma, or
leg ulcer, carries a significant risk of infection. Infection is less
likely from a shave or curette biopsy compared to a punch or
incisional approach. Although the work of Dixon et  al.
referred predominantly to oncologic surgery, their conclu-
sions are helpful when considering the need for prophylactic
antibiotics for biopsy procedures.16 Based on a prediction of
infection rate over 5%, antibiotics are considered for all pro-
cedures below the knee, wedge excisions of the lip and ear,
and lesions in the groin. Other relative indications for anti­
biotics are uncontrolled diabetes, alcoholism, malnutrition,
and morbid obesity (see Chapter 6).17
Systemic antibiotics may be given to prevent endocarditis.
Guidelines have been published recently.18 In order to be
effective and truly prophylactic, antibiotics should be admin-
istered 30 minutes before the procedure. Usually, a single
preoperative dose is preferred and the choice is affected by
the clinical setting. There is little evidence to support the use
of prophylactic topical antibiotics. The American Heart Asso-
ciation’s indications for prophylactic antibiotics have been
published elsewhere.
Anesthesia
Some biopsy procedures can be performed using topical
anesthesia only. EMLA (eutectic mixture of local anesthetics)
is 2.5% lidocaine in eutectic mixture with prilocaine 2.5%. It
also contains emulsifiers that increase penetration and absorp-
tion. It requires a minimum occlusion time of 1 hour for
superficial procedures but dermal anesthesia requires 2–3
hours. EMLA may be used without occlusion in genital skin
but is ineffective in thick stratum corneum as found on the
palms and soles (see Chapter 3).
Injection anesthesia for biopsies is usually intradermal using
lidocaine alone or with epinephrine 1 : 80 000 to 1 : 200 000
to aid hemostasis. Dogma states that epinephrine is contrain-
dicated in acral sites where a marked vasoconstriction could
in theory produce tissue necrosis. However, there is no evi-
dence to support this and several studies have not demon-
strated any significant complications.19 The importance of
careful administration of local anesthetic should not be
underestimated. Part of the patients judgement of the der-
matologic surgeon’s performance is based on how much user
Several studies have addressed the use of aspirin by patients
undergoing skin surgery. Overall, there appears to be a slightly
greater risk of serious bleeding complications but the risk is
low with meticulous hemostasis technique, so aspirin should
not be stopped. In a prospective study of 40 patients, only
three taking aspirin and three controls had excessive bleed-
ing.12 Another study showed no difference in bleeding
between 52 patients taking aspirin compared to 119 con-
trols.13 Finally, a study of 81 patients undergoing Mohs
surgery showed that nine (11.1%) had increased bleeding
while taking aspirin, with only two (3%) returning for redress-
ing, and one (1.5%) requiring another operation, compared
to control group values of 2% and 0.5%, respectively.9
Rarely, there may be a situation with a patient taking mul-
tiple agents, for example warfarin, aspirin, and clopidogrel,
or perhaps aspirin alone when the surgeon is keen to minimize
bleeding and it is then important to discuss with the patient’s
physician what can be done.
There is a theoretical risk of interaction of several
other oral drugs, including monoamine oxidase inhibitors,
β-blockers, and tricyclic antidepressants, with the use of local
anesthetic containing epinephrine, causing a hypertensive
crisis. However, with the small volume of local anesthetic
usually used and the weak concentration of epinephrine
(1 : 200 000), this does not appear to be clinically significant.
Informed consent
The word consent is derived from the Latin consentire
meaning to agree/approve/give permission. Informed consent
can be defined as ‘voluntary permission given by a subject for
medical care after being informed of the purpose, methods,
procedures, benefits, and risks.’ When obtaining consent, it
may be useful to include the following points:
• Nature of the biopsy procedure (diagnostic vs
therapeutic).
• Pain and/or discomfort may occur during the injection
of the anesthetic.
• A definitive diagnosis may not be rendered even after
adequate biopsy.
• A permanent scar of uncertain character will result from
the procedure.
• List of other possible complications.
• Recurrence of skin lesions is possible.
• Further treatment (surgical and/or medical) may be
necessary.
• Preoperative photographs may be taken as part of the
medical record or for possible publication in medical
journals and books.
A signed consent is desirable for all types of biopsies. It is
important to remember that patients forget information given
to them before surgical procedures and some may become
litiginous if complications arise. It has been demonstrated
that patients’ recall of 10 potential complications is only
26.5% at 20 minutes and 24.4% at 1 week after delivery of
written and verbal information before Mohs surgery.14
Preparation of the biopsy site15
Small shave, punch, and scissor biopsies are adequately per-
formed using clean or modified-sterile technique. Gowns,
face masks, and sterile fields are not strictly necessary, but
clean gloves help protect the physician from acquiring blood-

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Chapter 11  Skin Biopsy Techniques
holders, and gauze. If the lesion is poorly demarcated, its
extent can be outlined with a skin marker pen before the
procedure. For punch and ellipse biopsies, sterile technique
is indicated with appropriate skin preparation, and skin
draping should be used. The appropriate single-use instru-
ment can then be added to the tray, for example punch,
curette, blade, and sutures as needed.
A definitive excisional biopsy is indicated for a cutaneous
tumor if possible. However, an incisional biopsy is adequate
when the diagnosis is in doubt, the lesion is too large, non-
surgical treatment options are being considered, Mohs surgery
is being planned, or if the cosmetic consequences of complete
excision are significant. In these cases, the most representa-
tive area or areas should be sampled.
Bleeding after small skin biopsies is usually minimal and can
often be controlled with simple pressure with gauze, cotton
Q-tip or Gelfoam pledgets. Chemical hemostasis20 can be
achieved with 20% aluminum chloride hexahydrate in an
alcohol base (Driclor, Anhydrol Forte – used in treatment of
hyperhidrosis), Monsel’s solution (ferric subsulfate), trichlo-
roacetic acid, or silver nitrate. Monsel’s solution is the most
effective agent but it causes more tissue destruction and may
result in unwanted permanent pigmentation of the area.
Snip
Using a pair of sharp iris or gradle scissors, small polypoid
lesions, for example skin tags, can be pulled away from the
surface and snipped at the base. Hemostasis is rarely a problem
– usually simple pressure is all that is needed. The tag should
be pulled just enough to stabilize it because firmer pulling will
result in a wider cut including some non-involved skin around
the base. Larger lesions may need cauterization after the snip,
and in this case it is best to inject local anesthetic first.
Shave
Shave biopsy is generally reserved for benign exophytic
lesions, for example viral warts, seborrheic keratoses, intra-
discomfort the patient experiences. Comments like ‘I didn’t
feel a thing’ and ‘Is that it?’ are to be welcomed (Box 11.2).
Problems are rare but one should remain alert. Needle
phobia may provoke anxiety and fainting. Adverse reactions
to lidocaine may be allergic, anaphylactic, or idiosyncratic.
Both immediate and delayed hypersensitivity reactions can
occur (see Chapter 3).
 TECHNIQUES
Choosing the most appropriate way to sample the skin is
important. The decision rests on the nature of the clinical
problem (Table 11.2).
General points
Performance of these procedures places the operator at risk
of blood-borne infections. Accordingly, vaccination for hepa-
titis B is indicated, and universal precautions should be
observed by wearing gloves. Use of a surgical cap, surgical
mask and eye guard should be considered. Used sharp objects
(needles, punches, blades) should be disposed of in approved
Occupational Safety and Health Administration (OSHA)
containers. A biopsy tray should include alcohol pads, local
anesthetic, gloves, forceps, skin hooks, iris scissors, needle
Box 11.2  Minimizing the pain of local
anesthesia
 Distraction, e.g. pinching the skin before injection.
 Use fine needle and inject at 45° angle to skin surface.
 Inject slowly and intermittently.
 Reassuring talk and/or provide background music.
 Allow the patient to hold a nurse’s hand.
 Warm the anesthetic to body temperature.
 Subcutaneous injection.
 Buffer the solution with sodium bicarbonate.
Table 11.2  Factors influencing choice of biopsy
CLINICAL PROBLEM
TYPE OF DIAGNOSTIC BIOPSY
OTHER FACTORS
Generalized eruption
Incisional or punch
Active lesion with the transition to and including normal skin
If eruption occurs on the upper extremity, this site is preferable to the
lower extremity
Pigmented lesion2
Excisional biopsy
Large pigmented lesions, e.g. lentigo
maligna – a diagnostic incisional
biopsy across the diameter of the
lesion is preferred
Include a 2-mm peripheral margin of normal skin beyond the clinical
margin of the lesion, which may be determined by dermoscopy
Beware sampling error caused by a punch biopsy
If it is not possible to perform an incisional biopsy, then consider
multiple ‘scouting’ biopsies
Blistering disease
Incisional, including perilesional skin
Two specimens:
• Formalin fixed for routine hematoxylin and eosin preparation
• Michel’s medium for immunofluorescent preparation
BCC
Excision, punch, shave, curette
Choice of biopsy technique influenced by:
• anticipated type of BCC, e.g. superficial BCC may be biopsied by a shave
procedure, morphea-type BCC requires a punch or excisional biopsy
• location of lesion and degree of confidence in the clinical diagnosis
• expected eventual treatment
Ulcerated skin
Incisional
Sample the edge to avoid necrotic material

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Part 2  Essential Surgical Skills
of nevus tissue produces the same effect for this peripheral
tissue. Slicing a nevus completely flush often leads to a small
depressed scar which produces a shadow effect. Data on
cosmetic outcomes demonstrate that almost half of head and
neck lesions show no residual mark.22 On the trunk, the figure
is 30%. Pigmented moles will have some residual color in 25%
of cases.
A saucerization biopsy requires similar technique but the
excision includes the skin lesion plus a portion of the sur-
rounding skin down to the deep dermis or subcutaneous fat.
It is suited for lesions located on the epidermis and dermis
and heals by second intention with scarring. It can be a fast,
pragmatic excision procedure in the right clinical setting.
Curette
Curette biopsy is used on epidermal lesions when the tissue
is relatively soft and when there is a cleavage plain between
the lesion and the underlying dermis. It is suitable for mol-
luscum contagiosum, seborrheic keratosis (Figs 11.5 and
11.6), actinic keratosis, and selected cases of BCC. The tech-
nique is not suitable on lax skin such as the eyelids because
it pulls and tears rather than separates.
The two styles of curette are the cup-shaped, semisharp
Volkmann spoon type and the ultrasharp ring curettes.
Whichever is used, it is best to firm the surrounding skin with
a finger and thumb of one hand before taking the specimen
by a firm downward scooping motion of the curette through
the lesion. Usually multiple small fragments (curettings)
are obtained. The ring curette is so sharp that inadvertent
damage can be done and care is needed especially on thin
skin. Hemostasis is achieved with simple pressure, chemical
cautery, or light electrodesiccation, for example hyfrecation
(Figs 11.7 and 11.8).
Punch biopsy
The term ‘core’ or trephine biopsy is more readily understood
by the layman and accurately describes the process. The
dermal or compound melanocytic nevi, and remains a quick
and effective method that does not require suturing (Fig.
11.4). After preparation of the site with an alcohol wipe,
1–3 mL of local anesthetic is injected intradermally – thus
raising a wheal to elevate the lesion from the surrounding
skin. The fingers of the non-dominant hand apply three-point
pressure on the skin in order to stretch it taut. When the
entire lesion is to be removed by shave technique, the blade
is held parallel to the skin surface at the base of the lesion
and a cutting or sawing motion is used to cut horizontally
through the lesion at the level of the mid-dermis. The depth
of the biopsy is controlled by the angle of the blade. The edges
can then be curetted to remove remaining lesion or improve
the cosmetic result. Any form of blade can be used but excel-
lent control can be achieved with a flexible single- or double-
edge razor blade. The blade is gently bent between the thumb
and index finger, allowing the operator to control the size and
depth of the excision by increasing or decreasing the concav-
ity of the blade. Bleeding can be controlled with pressure
alone, chemical hemostasis, or light electrodesiccation. The
wound heals by second intention and typically re-epithelial-
izes in approximately 1 week.
Shave biopsy is not useful if the deep margin of a tumor
needs to be visualized. In the case of skin tumors, the aim is
to remove only sufficient tissue to make a diagnosis; a sliver
can be shaved off without anesthetic. However, many BCCs
have more than one growth pattern present and a shave
biopsy will not necessarily reveal the full extent of the
problem.21 Shave biopsy is not suitable if the clinician is trying
to distinguish between a keratoacanthoma-type squamous
cell carcinoma (SCC) and an invasive SCC.
When dealing with papular nevi the aim is to achieve a good
cosmetic result by removing most of the tissue and providing
material for analysis. Injecting the anesthetic into the nevus
helps to stiffen the tissue. The plane of removal should be
just above the surrounding skin so that natural shrinkage takes
the level of the central portion down to the level of the sur-
rounding normal skin. Light cautery to the remaining collar
Figure 11.4  Shave excision of a neurofibroma.
Figure 11.5  Curettage of seborrheic keratosis, left temple.

173
Chapter 11  Skin Biopsy Techniques
instrument is a hollow metal cylinder with a sharp cutting
edge and a plastic handle. Most clinicians use disposable
punches that range in diameter from 2 to 8 mm. Pathologists
generally prefer more than 2 mm of tissue to assess rashes
and so the smaller punches, if used at all for diagnostic work,
are reserved for certain tumors. Even a 4-mm specimen may
be inadequate if a pathologist wishes to use several stains.
Punch biopsies are easily mastered, are quick, and have a low
incidence of significant scarring, non-healing, bleeding, and
infection. The distinct advantage of a punch biopsy over the
shave biopsy is its ability to sample the full thickness of skin,
Figure 11.6  Curettage of seborrheic keratosis, left temple, from
opposite side.
Figure 11.7  Seborrheic keratosis removed in one piece and
superficial wound electrodesiccated.
Figure 11.8  Vaseline applied to the defect created by removal
of a seborrheic keratosis and a semipermeable adherent film
dressing is applied.
Figure 11.9  Red, scaly plaque, lower leg. Site for 6-mm
diameter incisional punch biopsy outlined with gentian violet.
Relaxed skin tension lines demonstrated.
allowing for evaluation of dermal pathology, and so it is the
technique most often used for a tissue diagnosis.
The specimen is taken, after anesthetizing the area, by a
rotational and downward movement. Stretching the skin at
right angles to relaxed skin tension lines will change the
defect from a circular to oval shape and minimize dog-ear
formation and aid linear closure (Figs 11.9–11.11). The
punch is withdrawn, and the specimen retrieved by use of a
skin hook, piercing it with a needle or by gently handling with
toothed forceps (Fig. 11.12). Care must be taken to tease out
the specimen and snip it off at the base to include the deeper
tissue (Fig. 11.13). If there is no fat attached, part of the
pathology may be missed – indeed a punch is unlikely to
provide adequate material from a deep process such as pan-
niculitis.
There are variations in design of the punch with windows
in the side of the cylinder to allow visualization and access to

174
Part 2  Essential Surgical Skills
mining is not routinely performed. Thought can be given to
the use of glue closure, steristrip adhesive tape closure, or a
single buried dermal suture24–26 if cosmetic considerations are
paramount, for example on a facial site. Occasionally a wound
is best left to heal by granulation27 because a suture would
tear the tissue or have no effect. This would be found with
Figure 11.11  Punch biopsy applied perpendicular to the skin
surface and rotated directly downward.
Figure 11.12  Specimen core lifted up gently with skin hook.
Figure 11.13  Specimen removed by snipping fat at attached
base.
Figure 11.14  Resultant oval defect.
Figure 11.15  End result after one central buried dermal suture
and two lateral cutaneous sutures.
free the specimen. Elliptical punches provide specimens
similar to the usual incisional biopsy (see below). Defects
arising from punch biopsies are usually sutured immediately,
which is hemostatic (Figs 11.14 and 11.15). One to three
interrupted or a ‘figure-of-8’ monofilament suture23 is used
and it is rarely necessary to use buried dermal sutures. Under-
Figure 11.10  Skin stretched at right angles to relaxed skin
tension lines prior to punch biopsy.

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Chapter 11  Skin Biopsy Techniques
traumatized specimen is to grasp the tissue in non-toothed
forceps and snip it off using sharp gradle scissors. Healing
from any method is usually excellent and scarring is rarely a
problem unless the vermilion border has been crossed, in
which case visible scars are frequent.
Genital skin:  The soft texture of genital skin makes ellip-
tical biopsy awkward with a tendency for the biopsy to be
frayed. On the vulva and shaft of the penis, it is possible to
grasp the tissue with non-toothed forceps and snip off the
specimen using sharp scissors, prior to suturing with a soft,
rapidly dissolving suture. On the glans, it is wise not to
attempt an ellipse because of the tendency to create a ragged
edge. It is better to make two parallel incisions and then use
sharp scissors to cut the base. Healing is always satisfactory
and any tendency for a protuberant area at the end of the
suture line settles quickly.
Palm and sole:  Injecting anesthetic directly into the thick
skin of the palms and soles is very uncomfortable. An alterna-
tive is to inject initially on the lateral or dorsal surface and
gradually work round to the relevant site. It should ensure
that each injection into the thicker skin penetrates an area
that has already been anesthetized. Stitches in these areas
should usually be left for 10 days to avoid dehiscence.
Anatomic danger areas
There may be a tendency to have less regard for underlying
structures when taking a diagnostic biopsy compared to fully
excising a lesion. Plunging a biopsy punch into the temple,
digit, or mandible could result in significant injury to a nerve
or artery (see Chapter 1).
 AFTERCARE
The principles of aftercare are no different from those fol-
lowing excisional surgery but may not need to be so rigorous.
The site of a shave or curette biopsy should be kept moist
with Vaseline to keep the area moist and so aid healing.
Routine use of a topical antibacterial agent, for example
polyfax ointment (bacitracin and polymyxin), should not be
encouraged. An occlusive water-permeable film dressing may
be used30 (e.g. Tegaderm for shave and curettes, Mepore for
punches) for 2 days, after which the site should be cleaned
daily. Advice to avoid strenuous exercise, elevate a depend-
ent limb, clean the wound site, and report to the physician
if any signs of infection develop (increasing pain, erythema,
and discharge) should be included on a patient information
leaflet.
 PITFALLS AND THEIR MANAGEMENT
Biopsy techniques share many of the same risks as excisional
surgery. The surgeon should be aware of this but patient
expectation may be on a different level. Patients simply may
not anticipate that the ‘small biopsy,’ ‘removal of a tiny piece
of skin,’ could result in a significant complication such as
hypertrophic scar, dehisced wound, or cellulitis. While these
unwanted effects may be unusual, it is important to warn the
patient appropriately.
a friable tumor, atrophic skin, or a tight edematous lower
limb. Aesthetic outcome from second intention healing of
punch biopsies can be satisfactory to excellent.28
Incisional ellipse
This is the standard approach to taking a diagnostic biopsy
and is covered in detail in Chapter 16. It is versatile because
it can be of any size and depth. If taken with vertical sides
and a horizontal base, it is easy for the pathology technician
to orientate for embedding and sectioning. As with elliptical
excisions, the direction of the long axis is usually along relaxed
skin tension lines that allows neat closure with sutures as
discussed above. Use of undermining can be considered. Use
of dermoscopy may help in identifying the most representa-
tive area.29
Incision and enucleation
This is the preferred technique for removal of benign subcu-
taneous lesions, for example epidermoid cysts and lipomas.
Indications for treatment include large size, pain, unsightly
appearance, and recurrent infection. Skin preparation is as for
a punch or ellipse biopsy, that is, sterile. Local anesthetic is
used as previously discussed (see Chapter 12).
Epidermoid cyst
An incision over the lesion down to the subcutis is made or
a small ellipse is fashioned. Next, the lesion is blunt dissected
from surrounding tissue to free it – it is then lifted out in one
piece with the cyst wall intact. Electrosurgical hemostasis is
used if needed. The defect is sutured usually in two layers.
Some clinicians prefer to make a small incision in the cyst
wall to drain some contents and allow the sac to be removed
through a smaller skin incision.
Lipoma
Normal saline may be injected into the lipoma to increase
pressure. A small incision is made over the center of the
nodule down to subcutis. Blunt dissection is then performed
and the lipoma can then be squeezed out in one piece or in
smaller fragments. Electrosurgical hemostasis is used if
needed. The defect is sutured usually in 2 layers.
Special sites
Scalp:  In order to avoid producing an area of alopecia, it is
important to make the plane of the biopsy parallel to the
direction of the hair shafts as they leave the scalp. Also the
biopsy should go into the subcutis to ensure the entire follicle
is visible for analysis. Scalp skin may bleed profusely and it
may be difficult to visualize a bleeding arteriole in the wound
edge. A cross-over stitch will often produce the required
hemostasis. Using a rapidly dissolving suture will obviate the
need for suture removal in thick hair-bearing skin.
Nail:  See Chapter 46.
Lip:  This is not only a highly vascular area but also the soft
texture can make it difficult to take a neat scalpel biopsy.
Using a chalazion clamp not only controls bleeding but also
firms the tissue and allows easier sampling of the mucosal
surface. Another method that can produce a precise non-

176
Part 2  Essential Surgical Skills
5. Cerio R, Archer CB. Clinical investigation of skin disorders. London:
Chapman & Hall; 1998.
6. Bakis S, Irwig L, Wood G, et al. Exfoliative cytology as a diagnostic test
for basal cell carcinoma: a meta-analysis. Br J Dermatol 2004;150:
829–836.
7. Otley CC. Perioperative evaluation and management in dermatologic
surgery. J Am Acad Dermatol 2006;54:119–127.
8. Stables G, Lawrence CM. Management of patients taking anticoagulant,
aspirin, non-steroidal anti-inflammatory and other anti-platelet drugs
undergoing dermatologic surgery. Clin Exp Dermatol 2002;27:
432–435.
9. Billingsley E, Maloney ME. Intraoperative and postoperative bleeding
problems in patients taking warfarin, aspirin and nonsteroidal anti-
inflammatory agents. Dermatol Surg 1997;23:381–385.
10. Alcalay J. Cutaneous surgery in patients receiving warfarin therapy.
Dermatol Surg 2001;27:756–758.
11. Blasdale C, Lawrence CM. Perioperative international normalized ratio
level is a poor predictor of postoperative bleeding complications in der-
matological surgery patients taking warfarin. Br J Dermatol 2008;
158:522–526.
12. Lawrence L, Sakuntabhai A, Tiling-Grosse S. Effect of aspirin and non-
steroidal anti-inflammatory drug therapy on bleeding complications
in dermatologic surgical patients. J Am Acad Dermatol 1994;31:
988–992.
13. Bartlett GR. Does aspirin affect the outcome of minor cutaneous surgery?
Br J Plastic Surg 1999;52:214–216.
14. Fleischman M, Garcia C. Informed consent in dermatologic surgery.
Dermatol Surg 2003;29: 952–955.
15. Roenigk RK, Roenigk HH. Roenigk and Roenigk’s dermatologic surgery:
principles and practice, 2nd edn. New York: Marcel Dekker; 1996.
16. Dixon AJ, Dixon MP, Askew DA, et al. Prospective study of wound
infections in dermatologic surgery in the absence of prophylactic anti­
biotics. Dermatol Surg 2006;32;819–827.
17. Wahie S, Lawrence CM. Wound complications following diagnostic skin
biopsies in dermatology inpatients. Arch Dermatol 2007;143:1267–
1271.
18. Wright TI, Baddour LM, Berbari EF, et al. Antibiotic prophylaxis in
dermatologic surgery: advisory statement 2008. J Am Acad Dermatol
2008;59:464–473.
19. Waterbrook AL, Germann CA, Southall JC. Is epinephrine harmful when
used with anesthetics for digital nerve blocks? Ann Emerg Med
2007;50:472–475.
20. Palm MD, Altman JS. Topical hemostatic agents: a review. Dermatol
Surg 2008:34:431–445.
21. Al-Ghamdi Y. Basal cell carcinoma: shave biopsy versus punch biopsy
technique in subtype diagnosis. J Am Acad Dermatol 1999;41:69–71.
22. Bong JL, Perkins W. Shave excision of benign facial melanocytic naevi:
a patient’s satisfaction survey. Dermatol Surg 2003;29:227–229.
23. McKerrow KJ, Grande DJ. Figure eight closure. J Am Acad Dermatol
1991;24:146–148.
24. Collins SC, Whalen JD. Surgical pearl: percutaneous buried vertical
mattress for the closure of narrow wounds. J Am Acad Dermatol
1999;41:1025–1026.
25. Alam M, Goldberg LH. Utility of fully buried horizontal mattress sutures.
J Am Acad Dermatol 2004;50:73–76.
26. Hohenleutner U, Egner N, Hohenleutner S, et al. Intradermal buried
vertical mattress suture as sole skin closure: evaluation of 149 cases. Acta
Derm Venereol 2000;80:344–347.
27. Bush JA, Ferguson MW, Mason T, et al. Skin tension or skin compression?
Small circular wounds are likely to shrink, not gape. J Plast Reconstr
Aesthet Surg 2008;61:529–534.
28. Christenson LJ, Philips PK, Weaver AL, et al. Primary closure vs second-
intention treatment of skin punch biopsy sites: a randomized trial. Arch
Dermatol 2005;141:1093–1099.
29. Schiffner R, Perusquia AM, Stolz W. One year follow-up of a lentigo
maligna: first dermoscopic signs of growth. Br J Dermatol 2004;
151:1087–1089.
30. Nemeth AJ, Eaglstein WH, Taylor JR, et al. Faster healing and less pain
in skin biopsy sites treated with an occlusive dressing. Arch Dermatol
1991;127:1679–1683.
 SUMMARY
The skin biopsy is an essential procedure that assists the
dermatologist and cutaneous surgeon in diagnosis and treat-
ment. The main skin biopsy techniques used are punch,
curettage, snip, shave, saucerization, elliptical and incisional
biopsy, and incision with enucleation. The choice of biopsy
technique is determined by the nature of the clinical scenario.
The preoperative evaluation for patients undergoing such pro-
cedures should be thorough, and informed consent must be
obtained with the appropriate amount of detail. Most biop-
sies can be performed under clean technique, but universal
precautions should be followed. The biopsy site should be
selected carefully. Complications are infrequent and gener-
ally minor, but can be minimized by appropriate selection of
patients and careful technique.
 REFERENCES
1. Lawrence C. An introduction to dermatological surgery, 2nd edn.
Edinburgh: Churchill Livingstone; 2002.
2. Tran KT, Wright NA, Cockerell CJ. Biopsy of the pigmented lesion –
when and how. J Am Acad Dermatol 2008;59:852–871.
3. Dengel L, Turza K, Noland MM, et al. Skin mapping with punch biopsies
for defining margins in melanoma: when you don’t know how far to go.
Ann Surg Oncol 2008;15:3028–3035.
4. Lauria G, Lombardi R, Camozzi F, et al. Skin biopsy for the diagnosis of
peripheral neuropathy. Histopathology 2009;54:273–285.
Pitfalls and their management
 Infection: increased likelihood in ulcerated lesions such as a
tumor, pyoderma, or leg ulcer, and certain locations – below
the knee, wedge excisions of the lip and ear, and lesions in the
groin.
 Dehiscence: the small size of most biopsies makes
dehiscence uncommon. However infection and unraveling of
sutures may contribute.
 Hypertrophic scar: more likely at some sites and in some
ethnic groups.
 Stretched scar: more common on the back and ventral
forearm.
 Suture marks: unlikely if sutures removed in 1 week or less.
 Bleeding/bruising: usually minor unless deep vessel is
damaged.
 Poor sampling: sample may be too small to allow
interpretation or it may not be representative of the entire
lesion, e.g. failure to identify an area of invasive melanoma in a
lentigo maligna.
 Allergy to local anaesthetic: history taken during preoperative
assessment should identify allergy – use preservative-free
lidocaine.
 Allergic contact dermatitis to ointment or tape: withdraw likely
source of allergen, treat with burst of moderate-potency topical
steroid, patch test as appropriate.

177
12
Incision, Draining, and
Exteriorization Techniques
Jeffrey A Squires MD and Frederick S Fish III MD FACP
Summary box
 When removing large cysts or lipomas, consider using dilute
local anesthetic as is performed with tumescent anesthesia.
 Be mindful of the regional anatomy. Lipomas on the forehead
may extend below the frontalis muscle and those on the
upper extremities can infiltrate into the muscle. Previously
removed cysts may be surrounded by fibrotic scar tissue.
 Prior to injecting local anesthesia, palpate the mass to
determine its mobility and draw the lateral margins and the
incision line.
 A cyst may be decompressed to allow easy removal through
a small incision.
 When cysts are mildly inflamed or have drainage, a short
course of oral antibiotic is reasonable.
 Inflamed or infected cysts and abscesses are drained by a
stab incision. The cavity is probed with a curette and irrigated.
Packing can be performed.
 INTRODUCTION
Subcutaneous lesions, such as lipomas and epidermal cysts,
are a common concern and are often found during the exam-
ination of the patient. Through the proper use of incision,
draining, and exteriorization techniques, physicians can effec-
tively treat their patients. This chapter describes techniques
for incision, draining, and exteriorization of several types of
subcutaneous lesions, the preoperative and postoperative
management, and the potential pitfalls and complications to
help ensure a successful outcome.
 HISTORY
The practice of incisional surgery has remained essentially
unchanged over the years. The origins of incisional surgery
date back to 1800 BC, where they can be found in the Egyp-
tian practice of medicine and surgery.1 Incisional surgery and
draining and exteriorization techniques are widely employed
for the removal of various benign subcutaneous processes
such as epidermal and pilar cysts, and lipomas. Incision,
drainage, and exteriorization of abscesses and infected,
inflamed cysts can also be accomplished by this method.
 PREOPERATIVE PREPARATION
Preoperative evaluation and vital signs, including blood pres-
sure and pulse, are always important to obtain (see Chapter 5).
When removing larger lesions, such as large cysts and lipomas,
avoid local anesthetics which are highly concentrated, and
consider diluting the anesthetic, as is performed with tumes-
cent anesthesia. One must also be aware of the surrounding
structures, taking into consideration the under­lying nerves,
blood vessels, and other important anatomic structures.
Removing subcutaneous masses in certain anatomic sites
and conditions can be challenging if one is not familiar with
the local anatomy. The surgeon must always be mindful
of the underlying anatomic structures. For example, lipomas
on the forehead are frequently found beneath the frontalis
muscle and can be difficult to mobilize and remove. Lipomas
of the upper extremities can infiltrate along the fascial planes
and into deeper muscular structures. Cysts, particularly, and
other subcutaneous lesions that have been previously treated
will often be surrounded by considerable fibrosis and scar
tissue, complicating their removal. In order to anticipate dif-
ficulty, careful palpation of the mass with the thumb and
forefinger, as well as both forefingers, is performed to assess
the mobility and character of the tissue surrounding the lesion
(Figs 12.1 and 12.2A). Areas of scar tissue are identified as
well as larger blood vessels and other underlying structures.
Before the anesthetic injection, it is useful to mark both
the lateral margins of the lesion to be removed and the
anticipated incision line parallel to the relaxed skin tension
lines. After the anesthetic is injected, the relaxed skin tension
lines may be difficult to see and small or deep subcutaneous
lesions may be difficult to palpate or locate.
 TECHNICAL ASPECTS
Lipomas
Clinically, lipomas are slow-growing, mobile masses with
lobulations that can range in size from a few millimeters to
over 20 cm and are usually encapsulated. Although they can
cause discomfort by pressing on nerves and may grow rapidly,
most lesions are asymptomatic, They may be solitary or mul-
tiple. The most common sites are the subcutaneous tissue of
the neck, shoulders, and back, followed by the forearms and
buttocks.2,3 Lipomas that occur on the forehead and scalp
present a special problem for removal.4 Infiltrating lipomas of

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Part 2  Essential Surgical Skills
sion can then be lengthened intraoperatively to facilitate
removal.
The local anesthetic is injected over and around and under
the lesion. By injecting all around the lesion and using a gen-
erous volume of anesthetic, the lesion can be partially dis-
sected from the surrounding tissue.
Make the skin incision along the previously inked line. After
making the incision, blunt dissection can usually be accom-
plished with a curved hemostat, Ragnell, or Metzenbaum scis-
sors. The lipoma will usually be lighter in color and firmer than
the surrounding adipose tissue. The lesion may be round or
oval but also may have a lobulated shape. Once the lipoma has
been dissected free, grasp it with a hemostat (Fig. 12.3) and
apply lateral compression to squeeze it through the skin inci-
sion (Fig. 12.2B). If the lipoma is too large for removal through
the existing incision, the incision can be lengthened. Be careful
to examine the base of the lipoma as it is removed, to avoid
damaging any underlying structures that may still be attached.
After the lipoma is removed, use skin hooks to expose the
wound base to identify bleeding and cauterize as necessary.
Meticulous hemostasis must be obtained when excising sub-
cutaneous lesions. The use of pressure dressings and/or drains
may be necessary due to the location or size of the lesion.
Drains, if employed, are typically removed in 72 to 96 hours.
Smaller dead spaces will usually not require any further
attention but larger defects may require approximation of the
subcutaneous tissue to decrease the risk of hematoma and
prevent dimpling of the overlying skin.
Wound closure is usually accomplished by approximating
the subcutaneous tissue and dermis with an absorbable suture
such as Vicryl (Ethicon Inc, Johnson & Johnson Co, Somer-
ville, NJ). The epidermal edges are then apposed with a
non-absorbable suture such as Prolene (Ethicon) or Ethilon
(Ethicon). Since the overlying skin is not excised, there is
little tension on the skin edge. For large lipomas and cysts, it
may be necessary to excise some overlying skin to flatten the
incision. On the face, a running subcuticular closure in com-
the upper extremities may be deep and involve the muscles,
as well as neural and vascular structures.5 Lipomas rarely
become inflamed. They are most commonly removed because
they become symptomatic or cosmetically objectionable.
Carefully mark the lateral margins of the lipoma with a
surgical marking pen, the planned incision preferably over the
center of the lesion and aligned within the relaxed skin
tension lines. Plan on an incision length of one-half to one-
third of the lesional diameter of the underlying lipoma. Most
lipomas will compress or mold with lateral pressure and can
be removed through a smaller incision allowing for a smaller,
more cosmetically acceptable scar. If one encounters a con-
siderably larger lesion, fibrosis, or other difficulties, the inci-
Figure 12.1  Palpation of subcutaneous growth with thumb and
forefinger to help delineate margins prior to surgery.
A
Finger pressure to deliver
cyst or lipoma through incision
B
Figure 12.2  (A) Palpation of subcutaneous mass with two forefingers may help further to detect surrounding fibrosis and mobility of
the subcutaneous growth. (B) Technique for application of firm finger pressure around lipoma (or cyst) to deliver it through incision.

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Chapter 12  Incision, Draining, and Exteriorization Techniques
careful dissection is carried out to free the lipoma along all
of its borders. Blunt scissors or a small hemostat work well.
After the superficial surface of the lipoma has been ade-
quately undermined, the deep surface of the lipoma is also
thoroughly undermined. Frontalis-associated lipomas can be
quite adherent to the underlying tissue. Small lesions may be
removed intact and larger lesions are sometimes removed in
pieces to avoid a larger incision. It is important to restore
good structural integrity to the forehead after the lipoma has
been removed. The submuscular fascia is reapproximated
using deep absorbable suture and then the frontalis muscle is
also reapproximated prior to closing the subcutaneous tissue.
A pressure dressing for 24 hours is helpful to avoid accumu-
lation of fluid in the dead space.
Infiltrating lipomas of the upper extremities can be both
intermuscular and intramuscular. The more common inter-
muscular variant arises in the intermuscular fascial septae
and may infiltrate into adjacent muscle. Intramuscular
lipomas arise within the muscle and are poorly demarcated.
These lipomas are frequently firmer than ordinary lipomas.7,8
bination with Steri-Strips (3M, New York, NY) and an adhe-
sive such as Mastisol (Ferndale Laboratories, Inc, Ferndale,
MI) works well. A running horizontal mattress suture also
provides good wound edge eversion and gives excellent results
(Fig. 12.4).
A clinical entity termed frontalis-associated lipoma of the
forehead presents special difficulty in removal.5 Forehead
lipomas can be found both within the frontalis muscle and
between the muscle and submuscular fascia (Fig. 12.5). In
removing these lipomas, care must be taken not to cause
undue damage to the frontalis muscle (see Chapter 1). Other
important structures to consider are the supraorbital and
supratrochlear neurovascular bundles. Because these lipomas
often lie deep to the frontalis muscle, the supraorbital and
supratrochlear neurovascular bundles can be injured if care is
not taken during removal. After making a horizontal incision
within the relaxed skin tension lines, the frontalis muscle is
located and carefully dissected vertically to seperate the
muscle fibres or partially resected to allow access to the
lipoma.6 Once the capsule of the lipoma becomes evident,
Figure 12.3  Lipoma being grasped with a hemostat to assist
with delivery through skin incision.
Figure 12.4  Incision closed with a running horizontal mattress
suture and simple interrupted sutures. Excellent wound edge
eversion is obtained with this closure.
A
Frontalis muscle
Lipoma
Subgaleal space
Deep fascial leaflet
Periosteum
Frontal bone
Epidermis
Dermis
Subcutaneous fat
Superficial fascial leaflet
Lipoma: important anatomic structures
B
Figure 12.5  (A) Forehead lipoma with (B) diagram highlighting
important anatomic structures.

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Part 2  Essential Surgical Skills
Epidermal cysts
Epidermal cysts are commonly encountered benign subcuta-
neous masses known by many synonyms such as epithelial
cysts, keratinous cysts, and sebaceous cysts. Epidermal cysts
are circumscribed lesions lined by stratified squamous epi-
thelium containing central keratinous material. They arise
from the presence of epidermal cells in the dermis. These
cells can be implanted by trauma, or existing cells (such as
those of the follicular infundibulum) can proliferate and
create a cystic mass due to a process such as pilosebaceous
occlusion.9,10
Clinically, an epidermal cyst usually presents as a dome-
shaped elevated mass protruding above the skin surface. One
may appreciate more of a yellowish white color as the cyst
enlarges and stretches the overlying skin. On palpation, the
cyst is usually freely mobile but may be restricted in move-
ment by surrounding fibrosis and scar tissue. Chronic inflam-
mation and irritation frequently can result in perilesional
fibrosis. Acute inflammation can lead to frank purulence
requiring incision and drainage of the cyst. On the overlying
skin surface, a central punctum or dilated pore is usually
present. Sites of predilection include the face, neck, and
trunk. The preauricular area is a commonly affected region
as well as the ear lobes. Solitary lesions predominate but
multiple lesions can be seen. Multiple lesions may be associ-
ated with Gardner syndrome and basal cell nevus syndrome.
Individual lesions can vary in size from a few millimeters to
many centimeters in diameter.9,10
In removing an epidermal cyst, try to identify the dilated
pore in the skin overlying the lesion. Once the pore is identi-
fied the planned incision line is marked in the relaxed skin
tension lines transecting the epidermal pore, if possible.
Injection of a local anesthetic agent will help to dissect the
cyst from the surrounding tissue. If considerable fibrosis or
scar tissue exists, little separation of the cyst from the sur-
rounding tissue will occur. However, care should be taken
not to inject directly into the cyst cavity, as this will cause
pain, cyst distention, and possible rupture.
Using a #15 blade, make a shallow incision through the
pore along the marked line. Some cysts are quite superficial,
so be careful not to make the incision too deep. If the cyst
has not previously been treated, one should visualize a white–
gray sac-like structure that should appear superficially near
the epidermal pore and then extend deeper toward the lateral
edges. Once the skin incision is made, beveling the scalpel
blade at an angle will decrease the chance of rupturing the
cyst wall. If the pore is large it can be removed. Once the
cyst wall has been identified, grasp the epidermal edge with
a skin hook (Fig. 12.7) and dissect the cyst wall free from
the surrounding skin and subcutaneous tissue with iris or
small Gibbs–Gradle scissors. Grasp the cyst with a hemostat
Most infiltrating lipomas of the upper extremities are
asymptomatic; however, they may cause pain by compressing
adjacent structures. In addition, weakness may occur due to
nerve compression. Radiologic studies including computed
tomography (CT) scans and magnetic resonance imaging
(MRI) are very useful in assisting with the diagnosis and
planning surgical treatment.7 It is very important to deter-
mine the extent of the lipoma prior to excision, to ensure
that it is completely removed. These infiltrating lipomas fre-
quently require an incision which is larger than for ordinary
lipomas.
Great care needs to be taken dissecting these lipomas free
from surrounding muscle and neuromuscular structures.
A multilayered closure which includes the fascia and subcu-
taneous tissue allows for optimal results. In larger cases a
drain, which is usually removed 24–48 hours postoperatively,
may be appropriate. For infiltrating lipomas in dangerous
anatomic locations such as overlying Erb’s point, dissection
may not be performed without a nerve stimulator (Fig. 12.6)
Figure 12.6  The expanding mass of the left neck made it
difficult for this 45-year-old woman to turn her head. At the time
of resection of the mass, the lipoma was found to be
interspersed with soft tissue, muscle, blood vessels, and the
spinal accessory nerve. During surgery by a head and neck
surgeon, the spinal accessory nerve was explored and found to
run within the lipoma. The nerve was preserved.
Lipomas
 Careful palpation to access depth and size.
 Mark planned incision line prior to anesthetic injection.
 Attempt to remove through smallest incision possible.
 Palpate thoroughly prior to closure to assure complete
removal.
 Close dead space for larger lesions.
Forehead lipomas
 Careful palpation to access depth and size.
 Mark planned incision within skin tension lines.
 Attempt to dissect frontalis muscle bundles in vertical
orientation if possible.
 Dissection to free lipoma much more difficult.
 Repair muscle and fascial planes if necessary.
Infiltrating lipomas of the upper extremities
 Difficult to access with palpation.
 CT scans and MRI very useful in preoperative planning.
 Lesions tend to be large and may be both intermuscular and
intramuscular.
 Dissect carefully from surrounding muscle and neurovascular
structures.

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Chapter 12  Incision, Draining, and Exteriorization Techniques
and deliver it through the incision if possible. Gentle lateral
compression will mold the cyst somewhat, allowing the cyst
to be delivered through a smaller incision. If the cyst is too
large for the incision, it can be decompressed by making a
small incision in the wall and with gentle lateral pressure
expressing some of the keratinous contents through the inci-
sion (Fig. 12.8). The partially collapsed cyst sac can then be
delivered more easily through the incision (Fig. 12.9). If the
lesion is difficult to excise, lengthening the incision may be
necessary. The incision can also be converted to a fusiform
excision if one encounters considerable fibrosis or scar.
During the removal, some cystic contents can contaminate
the wound. After removal, one should carefully irrigate the
wound with saline. Probe the wound gently with a curette to
remove any residual keratinous fragments (Fig. 12.10). If any
are found, irrigate the wound until none remain.11 Skin hooks
work well to retract the wound edges and thoroughly inspect
the margins of the wound for any residual cyst wall because
retained portions may lead to recurrence.
In closing the wound, one must consider dead space as
previously mentioned. Absorbable sutures such as Vicryl
(Ethicon) work well to close the subcutaneous tissue. Ethilon
(Ethicon) or Prolene (Ethicon) suture can be used to achieve
skin closure. Cysts that have been present for a long duration,
or which are large in size, can stretch the overlying skin,
leading to excess or redundant skin. This excess skin may
need to be trimmed and removed at the time of wound
closure. It is often reasonable to place the patient on a short
course of an oral antibiotic that covers for Staphylococcus and
Streptococcus spp. when excising cysts that are mildly inflamed
or have any drainage.
Variations in the technique may need to be employed if
the cyst is recurrent or was previously inflamed and/or
drained. These lesions usually have some fibrosis at the
periphery, making the lateral margins less well defined. They
are often adherent to the overlying skin. On careful palpation,
a lack of mobility and more ill-defined margins can usually be
appreciated. In the absence of clinically palpable fibrosis, one
should still anticipate its presence in a recurrent or previously
Figure 12.7  Skin hook being used to provide retraction while
the cyst wall is dissected free from the subcutaneous tissue
with a small curved iris scissor.
A
Dissection of cyst
B
Figure 12.8  (A) After dissecting the cyst free, lateral
compression can be used to extrude the cyst. If the incision is
too small to allow for easy removal, a small incision can be
made in the cyst and a portion of the cyst contents can be
removed. This will allow for the collapsed cyst sac to be
delivered more easily through the incision. (B) Technique for
dissection of cyst from wall.
inflamed lesion. If considerable fibrosis is encountered, the
best course is to perform a fusiform excision including the
fibrotic area and underlying cyst. This will usually result in a
longer scar than desired and more wound tension due to the
removal of the fusiform area of tissue. An alternative is to
sharply dissect through the fibrotic area, but care must be